Effects of the financial crisis and Troika austerity measures on health and health care access in Portugal

Austerity Measures and the Resilience of Zimbabwe's Healthcare System: Challenges and Solutions

Austerity measures have become a contentious topic, shaping the landscape of health care systems around the world. As governments grapple with economic challenges, the impact of austerity on health care has emerged as a critical concern. This study focuses on the consequences of austerity actions adopted by the Zimbabwean government under the Transitional Stabilization Program (TSP) from August 2018 to December 2025. This research examines the impact of austerity measures on Zimbabwe's health care sector, exploring its connections with health infrastructure and resources, accessibility and affordability of health care, health funding, health care inequalities, and the health care workforce. Using a quantitative approach and data from 970 participants, including the general populace, health care providers, and government officials, significant positive correlations between austerity measures and these health care variables were identified. The findings indicated a noteworthy positive correlation between the independent variable "austerity measures" and five dependent variables: health care accessibility and affordability, health care inequalities, infrastructure and resources, health care funding, and health care workforce. The t-statistics values exceeded the threshold of 1.96, with values of 5.085, 3.120, 6.459, 8.517, and 3.830, respectively. These findings highlight the importance of considering the effects of austerity on health care access, health funding, health care inequalities, health workforce, health infrastructure and resources development. Policymakers should prioritize equitable resource allocation and targeted investments to strengthen the resilience of the health care system during economic challenges. Understanding these associations is crucial for evidence-based policy decisions and fostering a more equitable and resilient health care system in Zimbabwe.

Insights from the EQUALS4COVID19 study on migrant mental health in Portugal: a cross-sectional mixed-methods approach

BACKGROUND

The COVID-19 pandemic and related disruptive consequences in the economic, health, and educational sectors have impacted people's lives, contributing to a context of increased economic and social vulnerability. The pandemic has revealed and accentuated social inequalities and discrimination based on racial or ethnic origin. This study aimed to contribute to the promotion of the mental health and well-being of migrant populations living in Portugal via the definition of an analytical framework and recommendations emerging from the EQUALS4COVID19 project.

METHODS

To gather information on the impact of the COVID-19 pandemic and resilience determinants among immigrants, a mixed-methods approach was implemented in 2022, combining a cross-sectional survey targeting immigrant adults in Portugal, focus groups with immigrants, focus groups with healthcare professionals, and in-depth individual interviews with stakeholders involved in the implementation of measures related to mental health and well-being during the pandemic. The analysis followed an integrated framework; quantitative data informed the script of qualitative data collection methods, and qualitative analysis informed the reinterpretation of quantitative data.

RESULTS

The survey with 604 Brazilian and Cape Verdean immigrants revealed that gender (being a woman) was associated with both psychological distress and depression-related symptomatology and that the perception of discrimination was a major risk factor for psychological suffering, while perceived social support and individuals' resilience characteristics were protective factors. Qualitative data provided deeper insights into these findings, revealing the ways mental health is affected by social structures, such as gender and ethnic hierarchies. Migrants tend to work in precarious jobs requiring physical presence, which, together with dense housing conditions, puts them at higher risk of infection. The deterioration of the economic conditions of the general population has also increased the perception of ethnic-racial discrimination, which was found to be related to the increase in insecurity and anxiety-related symptomatology among the migrant population. Newly arrived migrants, with reduced support networks, experienced a greater sense of insecurity as well as concern and anguish regarding relatives who live far away, in their home country. Migrant women reported greater family-related distress, including work-life balance problems.

CONCLUSIONS

Proposals to address mental health inequalities should be considered in the context of the necessary global changes both at the societal level and in the delivery of mental health services. Additionally, they should be considered with the active involvement of migrants, families, and communities in the design and delivery of mental health promotion and care processes.

Impact of the 2008 economic crisis on the burden of hepatitis B and C diseases in Southern European countries

BACKGROUND

The economic crisis that began in 2008 has severely affected Southern (Greece, Italy, Portugal, Spain) Western European (SWE) countries of Western Europe (WE) and may have affected ongoing efforts to eliminate viral hepatitis. This study was conducted to investigate the impact of the economic crisis on the burden of HBV and HCV disease.

METHODS

Global Burden of Diseases 2019 data were used to analyse the rates of epidemiological metrics of HBV and HCV acute and chronic infections in SWE and WE. Time series modelling was performed to quantify the impact of healthcare expenditure on the time trend of HBV and HCV disease burden in 2000-2019.

RESULTS

Declining trends in incidence and prevalence rates of acute HBV (aHBV) and chronic HBV were observed in SWE and WE, with the pace of decline being slower in the post-austerity period (2010-2019) and mortality due to HBV stabilised in SWE. Acute HCV (aHCV) metrics and chronic HCV incidence and mortality showed a stable trend in SWE and WE, whereas the prevalence of chronic HCV showed an oscillating trend, decreasing in WE in 2010-2019 (p < 0.001). Liver cancer due to both hepatitis infections showed a stagnant burden over time. An inverse association was observed between health expenditure and metrics of both acute and chronic HBV and HCV.

CONCLUSIONS

Epidemiological metrics for HBV and HCV showed a slower pace of decline in the post-austerity period with better improvement for HBV, a stabilisation of mortality and a stagnant burden for liver cancer due to both hepatitis infections. The economic crisis of 2008 had a negative impact on the burden of hepatitis B and C. Elimination of HBV and HCV by 2030 will be a major challenge in the SWE countries.

Social protection and the International Monetary Fund: promise versus performance

BACKGROUND

Countries in the Global South are currently facing momentous economic and social challenges, including major debt service problems. As in previous periods of global financial instability, a growing number of countries have turned to the International Monetary Fund (IMF) for financial assistance. The organization has a long track-record of advocating for extensive fiscal consolidation-commonly known as 'austerity'-for its borrowers. However, in recent years, the IMF has announced major initiatives for ensuring that its loans support social spending, thus aiding countries in meeting their development targets and the Sustainable Development Goals. To assess this track record, we collected spending data on 21 loans signed in the 2020-2022 period, including from all their periodic reviews up to August 2023.

RESULTS

We find that austerity measures remain a core part of the organization's mandated policies for its borrowers: 15 of the 21 countries studied here experience a decrease in fiscal space over the course of their IMF programs. Against this fiscal backdrop, social spending floors have failed to live up to their promise. There is no streamlined definition of these floors, thus rendering their application haphazard and inconsistent. But even on their own terms, these floors lack ambition: they often do not foresee trajectories of meaningful social spending increases over time, and, when they do, many of these gains are eaten up by soaring inflation. In addition, a third of social spending floors are not implemented-a much lower implementation rate from that for austerity conditions, which the IMF prioritizes. In several instances, where floors are implemented, they are not meaningfully exceeded, thus-in practice-acting as social spending ceilings.

CONCLUSIONS

The IMF's lending programs are still heavily focused on austerity, and its strategy on social spending has not represented the sea-change that the organization advertised. At best, social spending floors act as damage control for the painful budget cuts: they are instruments of social amelioration, underpinned by principles of targeted assistance for highly disadvantaged groups. Alternative approaches rooted in principles of universalism can be employed to build up durable and resilient social protection systems.

Crisis politics of dehumanisation during COVID-19: A framework for mapping the social processes through which dehumanisation undermines human dignity

The COVID-19 global pandemic is understood to be a multidimensional crisis, and yet undertheorised is how it reinforced the politics of dehumanisation. This article proposes an original framework that explains how dehumanisation undermines the human dignity of individuals with minoritised socio-economic identities during the COVID-19 pandemic. The framework identifies four interrelated mechanisms of crisis-driven dehumanisation: threat construction, expanded state coercion, reinforcement of hierarchies, and normalisation of deaths. The article argues that an understanding of these mechanisms is crucial for capturing the complexity of human rights deterioration during the COVID-19 pandemic. The article uses the plausibility probe method to demonstrate macro-processes of dehumanisation, with illustrative empirical examples from diverse societies during COVID-19. It proposes a framework for understanding these dehumanisation processes that can apply to other transnational crises.

Lessons From the Portuguese Solid Organ Donation and Transplantation System: Achieving Success Despite Challenging Conditions

Over the past two decades, Portugal has become one of the world leaders in organ donation and transplantation despite significant financial constraints. This study highlights how Portugal achieved success in organ donation and transplantation and discusses how this information might be used by other countries that are seeking to reform their national programs. To accomplish this goal, we performed a narrative review of relevant academic and grey literature and revised our results after consultation with two national experts. Our findings were then synthesized according to a conceptual framework for organ donation and transplantation programs. Our results revealed several key strategies used by the Portuguese organ donation and transplantation program, including collaboration with Spain and other European nations, a focus on tertiary prevention, and sustained financial commitment. This report also explores how cooperative efforts were facilitated by geographical, governmental, and cultural proximity to Spain, a world leader in organ donation and transplantation. In conclusion, our review of the Portuguese experience provides insight into the development of organ donation and transplantation systems. However, other countries seeking to reform their national transplant systems will need to adapt these policies and practices to align with their unique cultures and contexts.

A scoping review on the impact of austerity on healthcare access in the European Union: rethinking austerity for the most vulnerable

BACKGROUND

There is consensus that the 2008 financial and economic crisis and related austerity measures adversely impacted access to healthcare. In light of the growing debt caused by the COVID-19 crisis, it is uncertain whether a period of austerity will return.

OBJECTIVE

This study aims to provide a structured overview of the impact of austerity policies in the EU-28 zone, applied in response to the Great Recession, on access to health care for the adult population, using the five access dimensions by Levesque et al. (2013).

METHODS

This study followed the PRISMA extension for Scoping Reviews guideline. Medline (PubMed) and Web of Science were searched between February 2021 and June 2021. Primary studies in the English language published after the 1st of January 2008 reporting on the possible change in access to the healthcare system for the adult population induced by austerity in an EU28 country were included.

RESULTS

The final search strategy resulted in 525 articles, of which 75 studies were reviewed for full-text analysis, and a total of 21 studies were included. Results revealed that austerity policy has been primarily associated with a reduction in access to healthcare, described through four main categories: i) Increase in rates of reported unmet needs (86%); ii) Affordability (38%); iii) Appropriateness (38%); iv) and Availability and Accommodation (19%). Vulnerable populations were more affected by austerity measures than the general population when specific safeguards were not in place. The main affected adult vulnerable population groups were: patients with chronic diseases, elderly people, (undocumented) migrants, unemployed, economically inactive people and individuals with lower levels of education or socioeconomic status.

CONCLUSION

Austerity measures have led to a deterioration in access to healthcare in the vast majority of the countries studied in the EU-28 zone. Findings should prompt policymakers to rethink the fiscal agenda across all policies in times of economic crisis and focus on the needs of the most vulnerable populations from the health perspective.

How International Health System Austerity Responses to the 2008 Financial Crisis Impacted Health System and Workforce Resilience - A Realist Review

BACKGROUND

The Great Recession, following the 2008 financial crisis, led many governments to adopt programmes of austerity. This had a lasting impact on health system functionality, resources, staff (numbers, motivation and morale) and patient outcomes. This study aimed to understand how health system resilience was impacted and how this affects readiness for subsequent shocks.

METHODS

A realist review identified legacies associated with austerity (proximal outcomes) and how these impact the distal outcome of health system resilience. EMBASE, CINAHL, MEDLINE, EconLit and Web of Science were searched (2007-May 2021), resulting in 1081 articles. Further theory-driven searches resulted in an additional 60 studies. Descriptive, inductive, deductive and retroductive realist analysis (utilising excel and Nvivo) aided the development of context-mechanism-outcome configurations (CMOCs), alongside stakeholder engagement to confirm or refute emerging results. Causal pathways, and the interplay between context and mechanisms that led to proximal and distal outcomes, were revealed. The refined CMOCs and policy recommendations focused primarily on workforce resilience.

RESULTS

Five CMOCs demonstrated how austerity-driven policy decisions can impact health systems when driven by the priorities of external agents. This created a real or perceived shift away from the values and interests of health professionals, a distrust in decision-making processes and resistance to change. Their values were at odds with the realities of implementing such policy decisions within sustained restrictive working conditions (rationing of staff, consumables, treatment options). A diminished view of the profession and an inability to provide high-quality, equitable, and needs-led care, alongside stagnant or degraded working conditions, led to moral distress. This can forge legacies that may adversely impact resilience when faced with future shocks.

CONCLUSION

This review reveals the importance of transparent, open communication, in addition to co-produced policies in order to avoid scenarios that can be detrimental to workforce and health system resilience.

An impact of economic slowdown on health. New evidence from 21 European countries

Background

The economic slowdown affects the population's health. Based on a social gradient concept, we usually assume that this detrimental impact results from a lower social status, joblessness, or other related factors. Although many researchers dealt with the relationship between economy and health, the findings are still inconsistent, primarily related to unemployment. This study reinvestigates a relationship between the economy's condition and health by decomposing it into macroeconomic indicators.

Methods

We use data for 21 European countries to estimate the panel models, covering the years 1995–2019. Dependent variables describe population health (objective measures – life expectancy for a newborn and 65 years old, healthy life expectancy, separately for male and female). The explanatory variables primarily represent GDP and other variables describing the public finance and health sectors.

Results

(1) the level of economic activity affects the population’s health – GDP stimulates the life expectancies positively; this finding is strongly statistically significant; (2) the unemployment rate also positively affects health; hence, increasing the unemployment rate is linked to better health – this effect is relatively short-term.

Conclusions

Social benefits or budgetary imbalance may play a protective role during an economic downturn.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13740-6.

Evolução da estrutura e resultados da Atenção Primária à Saúde no Brasil entre 2008 e 2019

Resumo Descreve a evolução da estrutura e resultados da Atenção Primária à Saúde (APS) no Brasil, entre 2008 e 2019. Foram calculadas a mediana de variáveis como: despesa per capita em APS por habitante coberto, cobertura da APS e as taxas de mortalidade e internações por condições sensíveis à atenção primária (CSAP) de 5.565 municípios brasileiros estratificados segundo porte populacional e quintil do Índice Brasileiro de Privação (IBP) e analisada a tendência mediana no período. Houve aumento de 12% na mediana da despesa em APS. A cobertura da APS expandiu, sendo que 3.168 municípios apresentaram 100% de cobertura em 2019, contra 2.632 em 2008. A mediana das taxas de mortalidade e internações por CSAP aumentou 0,2% e diminuiu 44,9% respectivamente. A despesa em APS foi menor nos municípios com maior privação socioeconômica. Quanto maior o porte populacional e melhores as condições socioeconômicas dos municípios, menor a cobertura da APS. Quanto maior a privação socioeconômica dos municípios, maiores foram as medianas das taxas de mortalidade por CSAP. Este estudo demonstrou que a evolução da APS foi heterogênea e está associada tanto ao porte populacional como às condições socioeconômicas dos municípios.

Evolution of the structure and results of Primary Health Care in Brazil between 2008 and 2019

Abstract This paper describes the structure and results of Primary Health Care (PHC) in Brazil between 2008 and 2019. The medians of the following variables were calculated: PHC spending per inhabitant covered, PHC coverage, and rates of mortality and hospitalizations due to primary care sensitive conditions (PCSC), in 5,565 Brazilian municipalities stratified according to population size and quintile of the Brazilian Deprivation Index (IBP), and the median trend in the period was analyzed. There was a 12% increase in median PHC spending. PHC coverage expanded, with 3,168 municipalities presenting 100% coverage in 2019, compared to 2,632 in 2008. The median rates of PCSC mortality and hospitalizations increased 0.2% and decreased 44.9%, respectively. PHC spending was lower in municipalities with greater socioeconomic deprivation. The bigger the population and the better the socioeconomic conditions were in the municipalities, the lower the PHC coverage. The greater the socioeconomic deprivation was in the municipalities, the higher the median PCSC mortality rates. This study showed that the evolution of PHC was heterogeneous and is associated both with the population size and with the socioeconomic conditions of the municipalities.

Impact of austerity programs: Evidence from the Italian national health service

Austerity measures are widely adopted to cope with financial straits. Since 2007 Italy has operated a financial recovery program (Piani di Rientro, PdR) in certain regions of the country. This provides an interesting setting for an intra-national analysis of the differences between the regions under a PdR program and those which are not. In the regions under a PdR, efforts to achieve economic sustainability and fiscal balance have impacted on healthcare indicators, resulting in a reduction in healthcare resources, an increase in taxes, and a general weakening of regional healthcare systems since the introduction of the program more than a decade ago. The detrimental effects of the austerity measures have become evident. As the regions under a PdR have demonstrated a sufficient level of economic stability, the national government should start revising its austerity strategy to prevent further widening of gaps in healthcare performance between regions.

The cost of privatization to the profession: Media representation of Audiology in Australia

PURPOSE

To investigate how the profession of audiology was represented in the media in Australia and how the increased privatisation of the profession may have shaped this representation.

METHOD

A systematic search of English language media records was conducted from January 1/1/00 - 17/7/20 using ANZ News Stream, TV News, Google News, and INFORMIT. Twenty-four of 1056 originally identified articles were retained. The findings were extracted and synthesised.

RESULTS

Context and content analyses were preformed, revealing a predominantly negative portrayal of Audiology as a profession in 21 of 24 (87.5%) articles. Predominant themes included: sales driven by incentives, predatory strategies and malpractice, non-regulation and privatisation of the hearing care industry, and conflict of interest.

CONCLUSION

The media was found to highlight consumer mistrust in the profession in recent years. Increased regulation of the profession of audiology is recommended to protect the population against exploitative practices and to renew faith in the profession by the public.

Migrants’ Health Policies and Access to Health Care in Portugal within the European Framework

Migratory flows have a specific influence in the European and Portuguese demographic context. Societies’ commitment to ensure fundamental rights of all citizens and migrants includes the promotion of health. This study aims to describe migrants’ health policies and access to the health system in Portugal within the European framework. We carried out a mixed methods approach, analyzing health policies in European Union countries and public health key indicators from statistical secondary data collected from Eurostat and Migrant Integration Policy Index. This data was complemented with a survey applied to immigrants living in Portugal. Portugal is a European country known for its favorable immigrant integration policies and has developed access to the health care system. However, our study has shown that greater investment is needed to overcome limitations or social inequalities which inhibit migrants’ access. Additionally, we sought to present a comparative analysis between Portugal and European Union countries, which can contribute to improve health systems within the current crisis.

Organizational Commitment and Intention to Leave of Nurses in Portuguese Hospitals

Intention to leave is influenced by the commitment and individual and structural factors. It is a critical dimension in health systems due to the shortage of professionals and the potential impact on the quality of care. The present paper: (i) characterizes organizational commitment and intention to leave; (ii) analyzes the relationship between structural factors (such as, work environment and nurse staffing), individual factors (age), and nurses’ organizational commitments and intention to leave; and (iii) analyzes the differences in the intention to leave and in the organizational commitment according to service specialty, nurses’ specialization, and contractual relationship in Portuguese public hospitals. A cross-sectional study was conducted with a sample of 850 nurses from 12 public hospitals units. The results show a high affective and continuance commitment of nurses with the hospital, and a reduced tendency of the intention to leave. A significant positive association was also found between the intent to leave and individual/structural factors. Organizational commitment and intention to leave levels are satisfactory, despite the influence of several factors, such as nurse staffing, work environment, or other opportunities for professional development. The results identify particularly sensitive areas that, through adequate health and management policies, can reduce nurses’ intentions to leave and promote the sustainability of the health system.

A review of the continuous professional development system for pharmacists

BACKGROUND

The Portuguese Pharmaceutical Society (PPS) implemented a system of Continuous Professional Development (CPD) for pharmacists in 2004. This system has evolved throughout the years, and currently all active pharmacists in Portugal are required to participate in the CPD program. Each CPD cycle takes 5 years. In each cycle, pharmacists must collect 15 CPD points, through participation in educational activities. The PPS accreditation process is managed via an online platform, where education/training providers, as well as pharmacists themselves, can submit educational activities for accreditation. Pharmacists may access their CPD status and assess their development at any point. The objective of this study was to analyze and review the educational activities submitted by providers over a 11-year period (2009-2019).

METHODS

Data from activities were retrieved from the PPS CPD online platform. All educational activities were labeled according to the area of pharmaceutical professional focus, type of promoter, and activity type.

RESULTS

During the study 3685 activities were analyzed. Over the last decade, submitted activities for accreditation increased in 52.6%. A significantly high proportion (98.9%) of these activities has been accredited. Promoters of activities were mostly pharmacies sectoral associations (29.6%), consultancy/training companies (19.6%), the PPS (18.5%), pharmaceutical industry (17.7%) and wholesalers' consortia (9.0%). Academia represented only 2.3% of the total amount of educational activities. The most frequent topics were related to "pharmacology & pharmacotherapy" (9.9%), followed by "counselling" (9.8%) and "management & administration" (7.2%). The most accredited type of activities was face-to-face (68.9%) and e-learning trainings (13.1%).

CONCLUSIONS

This study shows increasing interest in submitting CPD activities for accreditation between 2009 and 2019, but it also demonstrates that Academia could play a more interventive role in the lifelong learning education of Portuguese pharmacists.

Household Food Security and Associated Factors among Portuguese Children

This study investigated the household food insecurity (HFI) among Portuguese children following the last world financial crisis. A cross-sectional study was conducted on 4737 Portuguese children (3-11 yrs). Socio-demographics, food insecurity, and household geographic location were assessed via questionnaire. Nutritional status was measured. Following the economic crisis, 14.2% of school children and 12.0% of preschool children experienced HFI. Preschool children having parents with low and medium parental education (paternal: OR = 4.4; 95% CI 2.7-7.1 and OR = 2.4; 95% CI 1.5-3.6; maternal: OR = 2.2; 95% CI 1.4-3.5 and OR = 1.6; 95% CI 1.1-2.3), living in the south (OR = 1.4; 95% CI 1.0-2.0) and being overweight/obese (OR = 1.1; 95% CI 0.7-1.3) were more likely to experience HFI than food secure household peers. Higher OR of belonging to a food insecure household were observed in school-aged children with low and medium parental education (paternal: OR = 2.9; 95% CI 1.9-4.6 and OR = 1.7; 95% CI 1.1-2.5; maternal: OR = 2.5; 95% CI 1.6-3.9 and OR = 2.3; 95% CI 1.6-3.3), living in Coimbra (OR = 1.7; 95% CI 1.1-2.6) and being overweight/obese (OR = 1.3; 95% CI 0.8-1.5) compared to food secure household peers. Data are instructive and support the need to increase awareness of HFI, reduce its incidence in overweight/obese children from low socio-economic status families and specific geographic areas, and increase food availability based on local ecology.

Trends of amenable deaths due to healthcare within the European Union countries. Exploring the association with the economic crisis and education

The study of premature deaths from causes that are generally preventable given the current availability of healthcare - called amenable deaths due to healthcare - provides information on the quality of services. However, they are not only impacted by healthcare characteristics: other factors are also likely to influence. Therefore, identifying the association between amenable deaths due to healthcare and health determinants, such as education, might be the key to preventing these deaths in the future. Still unclear however, is how this works and how amenable deaths due to healthcare are distributed and evolve within the European Union (EU) below the national level. We therefore studied the geographical and temporal patterns of amenable deaths due to healthcare in the 259 EU regions from 1999 to 2016, including the 2007-2008 financial crisis and the post-2008 economic downturn, and identified whether any association with education exists. A cross-sectional ecological study was carried out. Using a hierarchical Bayesian model, we estimated the average smoothed Standardized Mortality Ratios (sSMR). A regression model was also applied to measure the relative risks (RR) at 95% credible intervals for cause-specific mortality association with education. Results show that amenable deaths due to healthcare decreased globally. Nevertheless, the decrease is not the same across all regions, and inequalities within countries do persist, with lower mortality ratios seen in regions from Central European countries and higher mortality ratios in regions from Eastern European countries. Also, the evolution trend reveals that after the financial crisis, the number of these deaths increased in regions across almost all EU countries. Moreover, educational disparities in mortality emerged, and a statistical association was found between amenable deaths due to healthcare and early exit from education and training. These results confirm that identifying and understanding the background of regional differences may lead to a better understanding of the amenable deaths due to healthcare and allow for the application of more effective policies.

The Great Recession weighted on Portuguese children: A structural equation modeling approach considering eating patterns

OBJECTIVES

Further evidence on how the Great Recession was associated with childhood obesity is needed, particularly when the world is facing a new and severe economic downturn caused by the COVID-19 pandemic. This study explores: (1) the direct association of the 2008's economic crisis with eating patterns and body mass index (BMI), among children, independently of their socioeconomic status (SES), and (2) the indirect association between the crisis and children's BMI, by using eating patterns as mediators.

METHODS

A sample of children (n = 8472, mean age: 7.17 years old, 50.8% male) was recruited in schools from the cities of Porto, Coimbra and Lisbon, Portugal. Children's height and weight were objectively measured; BMI was calculated. Other data were collected by a parental questionnaire. A structural equation modeling studied the associations between the economic crisis impact, eating patterns, and BMI; model was adjusted for SES.

RESULTS

Children in families that reported a greater impact of the economic crisis showed higher consumption of unhealthy food items and lower consumption of healthy foods, regardless of SES. Indirectly, children whose parents scored higher in the economic crisis impact had higher BMI mediated by a higher consumption of cakes/chocolates and lower intake of vegetables/salads.

CONCLUSIONS

The economic crisis was associated with higher BMI and unhealthy eating patterns. Efforts to promote healthy diets and weight are needed at a population level rather than for specific social classes, particularly in the face of a new economic crisis caused by the COVID-19 pandemic.

Development of medicines consumption in Portugal before and during the financial crisis

BACKGROUND

In May 2011, the Portuguese Government signed a Memorandum of Understanding with the European Commission, the European Central Bank and the International Monetary Fund, including detailed measures to control health costs, allowing Portugal to receive a financial rescue package. This study aims to investigate medicines utilization in the outpatient sector during Troika's financial rescue.

METHODS

Using Defined Daily Dose per million inhabitants per year as a measurement unit, we compared medicines utilization with other relevant indicators over 5-year intervals for a total period of 20 years, based on a built-in inventory of national outpatient drug use using the Intercontinental Medical Statistics Health and Anatomical Therapeutic Chemical index of the World Health Organization databases. The calculation was made on the basis of both compound and year-on-year growth rates.

RESULTS

With the exception of the interval 2009-11, an absolute rise in consumption was observed over the 20-year period. The downturn occurred prior to financial rescue, when expenditure management mechanisms were already in place, and coincided with an increase in out-of-pocket spending. With the decline of cost for patients, the access trend returned to being positive, but at a slower pace.

CONCLUSION

The rise in out-of-pocket and austerity measures may have led to decreased access to medicines. The findings of this study suggest that this impact was influenced by public cost-saving policies implemented even before the financial rescue. The results show that price reduction attenuated the repercussion of the measures.

Investigating unmet need for healthcare using the European Health Interview Survey: a cross-sectional survey study of Luxembourg

OBJECTIVES

We investigate the prevalence of unmet need arising from wait times, distance/transportation and financial affordability using the European Health Interview Survey. We explore associations between individual characteristics and the probability of reporting unmet need.

DESIGN

Cross-sectional survey conducted between February and December 2014.

SETTING AND PARTICIPANTS

4004 members of the resident population in private households registered with the health insurance fund in Luxembourg aged 15 years and over.

OUTCOME MEASURES

Six binary variables that measured unmet need arising from wait time, distance/transportation and affordability of medical, dental and mental healthcare and prescribed medicines among those who reported a need for care.

RESULTS

The most common barrier to access arose from wait times (32%) and the least common from distance/transportation (4%). Dental care (12%) was most often reported as unaffordable, followed by prescribed medicines (6%), medical (5%) and mental health (5%) care. Respondents who reported bad/very bad health were associated with a higher risk of unmet need compared with those with good/very good health (wait: OR 2.41, 95% CI 1.53 to 3.80, distance/transportation: OR 7.12, 95% CI 2.91 to 17.44, afford medical care: OR 5.35, 95% CI 2.39 to 11.95, afford dental care: OR 3.26, 95% CI 1.86 to 5.71, afford prescribed medicines: OR 2.22, 95% CI 1.04 to 4.71, afford mental healthcare: OR 3.58, 95% CI 1.25 to 10.30). Income between the fourth and fifth quintiles was associated with a lower risk of unmet need for dental care (OR 0.29, 95% CI 0.16 to 0.53), prescribed medicines (OR 0.38, 95% CI 0.17 to 0.82) and mental healthcare (OR 0.17, 95% CI 0.05 to 0.61) compared with income between the first and second quintiles.

CONCLUSIONS

Recent and planned reforms to address waiting times and financial barriers to accessing healthcare may help to address unmet need. In addition, policy-makers should consider additional policies targeted at high-risk groups with poor health and low incomes.

Space-time clustering and temporal trends of hospitalizations due to pulmonary tuberculosis: potential strategy for assessing health care policies

BACKGROUND

Tuberculosis (TB) causes pressure on healthcare resources, especially in terms of hospital admissions, despite being considered an ambulatory care-sensitive condition for which timely and effective care in ambulatory setting could prevent the need for hospitalization. Our objectives were to describe the spatial and temporal variation in pulmonary tuberculosis (PTB) hospitalizations, identify critical geographic areas at municipality level and characterize clusters of PTB hospitalizations to help the development of tailored disease management strategies that could improve TB control.

METHODS

Ecologic study using sociodemographic, geographical and clinical information of PTB hospitalization cases from continental Portuguese public hospitals, between 2002 and 2016. Descriptive statistics, spatiotemporal cluster analysis and temporal trends were conducted.

RESULTS

The space-time analysis identified five clusters of higher rates of PTB hospitalizations (2002-16), including the two major cities in the country (Lisboa and Porto). Globally, we observed a -7.2% mean annual percentage change in rate with only one of the identified clusters (out of six) with a positive trend (+4.34%). In the more recent period (2011-16) was obtained a mean annual percentage change in rate of -8.12% with only one cluster identified with an increase trend (+9.53%).

CONCLUSIONS

Our results show that space-time clustering and temporal trends analysis can be an invaluable resource to monitor the dynamic of the disease and contribute to the design of more effective, focused interventions. Interventions such as enhancing the detection of active and latent infection, improving monitoring and evaluation of treatment outcomes or adjusting the network of healthcare providers should be tailored to the specific needs of the critical areas identified.

Structural Violence and Health-Related Outcomes in Europe: A Descriptive Systematic Review

In recent years, there has been a revival of the term “structural violence (SV)” which was coined by Johan Galtung in the 1960s in the context of Peace Studies. “Structural violence” refers to social structures—economic, legal, political, religious, and cultural—that prevent individuals, groups and societies from reaching their full potential. In the European context, very few studies have investigated health and well-being using an SV perspective. Therefore, this paper sought to systematically and descriptively review studies that used an SV framework to examine health-related outcomes across European countries. The review included two studies each from Spain and France, one each from the UK, Ukraine and Russia, and another study including the three countries Sweden, Portugal and Germany. With the exception of one mixed-method study, the studies used a qualitative design. Furthermore, the eight studies in the review used different conceptualizations of SV, which indicates the complexity of using SV as a concept in public health in the European context. Future research that attempts to identify and standardize measures of SV is needed; the knowledge gained is hoped to inform appropriate interventions aiming to reduce the effects of SV on population health.

Economic and financial crisis based on Troika's intervention and potentially avoidable hospitalizations: an ecological study in Portugal

BACKGROUND

Hospitalisations for Ambulatory Care Sensitive Conditions (ACSC) cause harm to users and to health systems, as these events are potentially avoidable. In 2009, Portugal was hit by an economic and financial crisis and in 2011 it resorted to foreign assistance ("Memorandum of Understanding" (2011-2014)). The aim of this study was to analyse the association between the Troika intervention and hospitalisations for ACSC.

METHODS

We analysed inpatient data of all public NHS hospitals of mainland Portugal from 2007 to 2016, and identified hospitalisations for ACSC (pneumonia, chronic obstructive pulmonary disease, hearth failure, hypertensive heart disease, urinary tract infections, diabetes), according to the AHRQ methodology. Rates of hospitalisations for ACSC, the rate of enrollment in the employment center and average monthly earnings were compared among the pre-crisis, crisis and post-crisis periods to see if there were differences. A Spearman's correlation between socioeconomic variables and hospitalisations was performed.

RESULTS

Among 8,160,762 admissions, 892,759 (10.94%) were classified as ACSC hospitalizations, for which 40% corresponded to pneumonia. The rates of total hospitalisations and hospitalisations for ACSC increased between 2007 and 2016, with the central and northern regions of the country presenting the highest rates. No correlations between socioeconomic variables and hospitalisation rates were found.

CONCLUSIONS

During the period of economic and financial crisis based on Troika's intervention, there was an increase in potentially preventable hospitalisations in Portugal, with disparities between the municipalities. The high use of resources from ACSC hospitalisations and the consequences of the measures taken during the crisis are factors that health management must take into account.

Less obesity but higher inequalities in Portuguese children: Trends of childhood obesity between 2002-2016

AIM

To observe the trends of overweight and obesity among Portuguese children from 2002 to 2016, before and during the years of the economic crisis, and compare these trends according to family's socio-economic position (SEP).

METHODS

Prevalence rates were calculated using data from six studies providing comparable estimates from 2002, 2009, 2011, 2013 and 2016 for children aged 6-10-years living in the Portuguese Midlands (n = 7192; 50.2% girls). Height and weight were objectively measured; children and family characteristics were collected by standard questionnaires. A logistic regression was used to test the association between variables.

RESULTS

Between 2002 and 2016, there was a decrease in the prevalence of overweight and obesity, which reached a statistical significance for girls. The prevalence of overweight, including obesity, was high (low-SEP = 30.5%; high-SEP = 20.5%) and a widening of socio-economic inequalities was found. Socio-economically disadvantaged children had more than 2 times the odds of having obesity than children from higher-SEP, even after adjusting for sex, physical activity and screen-time.

CONCLUSION

While a decrease in overall rates of overweight and obesity was observed from 2002 to 2016, the social inequalities have been widened which suggest the need for public efforts to promote healthy weight at a population level, especially in lower socio-economic classes.

The unequal effects of austerity measures between income-groups on the access to healthcare: a quasi-experimental approach

BACKGROUND

The Great Recession, starting in 2008, was characterized by an overall reduction in living standards. This pushed several governments across Europe to restrict expenditures, also in the area of healthcare. These austerity measures are known to have affected access to healthcare, probably unevenly among social groups. This study examines the unequal effects of retrenchment in healthcare expenditures on access to medical care for different income groups across European countries.

METHOD

Using data of two waves (2008 and 2014) of the European Union Statistics of Income and Living Conditions survey (EU-SILC), a difference-in-differences (DD) approach was used to analyse the overall change in unmet medical needs over time within and between countries. By adding another interaction, the differences in the effects between income quintiles (difference-in-difference-in-differences: DDD) were estimated. To do so, comparisons between two pairs of a treatment and a control case were made: Iceland versus Sweden, and Ireland versus the United Kingdom. These comparisons are made between countries with recessions equal in magnitude, but with different levels of healthcare cuts. This strategy allows isolating the effect of cuts, net of the severity of the recession.

RESULTS

The DD-estimates show a higher increase of unmet medical needs during the Great Recession in the treatment cases (Iceland vs. Sweden: + 3.24 pp.; Ireland vs. the United Kingdom: + 1.15 pp). The DDD-estimates show different results over the two models. In Iceland, the lowest income groups had a higher increase in unmet medical needs. This was not the case in Ireland, where middle-class groups saw their access to healthcare deteriorate more.

CONCLUSION

Restrictions on health expenditures during the Great Recession caused an increase in self-reported unmet medical needs. The burden of these effects is not equally distributed; in some cases, the lower-income groups suffer most. The case of Ireland, nevertheless, shows that certain policy measures may relatively spare lower-income groups while affecting middle-class income groups more. These results bring in evidence that policies can reduce and even overshoot the general effect of income inequalities on access to healthcare.

Impact of macro-socioeconomic determinants on sustainable perinatal health care in Portugal: a qualitative study on the opinion of healthcare professionals and experts

BACKGROUND

The WHO identified the importance of macro-socioeconomic determinants and political context as interlinked key factors affecting healthcare quality and health equity. As a response to the recent economic and financial crisis, Portugal approved in 2011 the Economic Adjustment Programme (EAP) to obtain financial assistance from the Troika in order to reduce public debt. This study aims to analyse the impact of the economic crisis and the EAP on perinatal healthcare quality for very preterm (VPT) and/or very low birth weight (VLBW) infants, as perceived by healthcare professionals and experts, within the health administrative regions of the two major metropolitan areas in Portugal.

METHODS

A qualitative approach was applied to receive an in-depth understanding and accomplish perspective variability. A purposive sampling technique was used. Semi-structured interviews were conducted with twenty-one healthcare professionals and experts between October 2018-July 2019. Inductive thematic analysis was performed which encompassed a five-step categorization procedure. Data analysis was undertaken by utilizing Nvivo2011 software. Evolved themes were then associated with WHO's Quality Standards on Maternal and New-born Care. A framework on the impact of macro-socioeconomic determinants on perinatal health care quality was developed.

RESULTS

Although participants did not perceive the quality of perinatal care had deteriorated, the analysis of their accounts on work experience revealed that it was indeed adversely modified in all WHO Quality Standards. Health care provision was perceived as detrimental in five main areas: 1) Availability of human resources; 2) Functional referral systems; 3) Competent and motivated human resources; 4) Emotional support; and 5) Essential physical resources available. Policy reforms by the EAP resulted in reduced timeliness of care, increased waiting times, cuts in sequence and duration of consultations, and deficiencies in follow-up care for VPT/VLBW infants and their mothers. The EAP directly influenced working environment of healthcare professionals by causing stress, burnout, work absence, and brain drain.

CONCLUSION

An interrelation between macro-socioeconomic determinants and perinatal health care quality was disclosed. The economic crisis and EAP have adversely modified equitable perinatal health care quality for VPT/VLBW infants and their mothers. Our findings underlined the negative impact of austerity policies on vulnerable populations.

[Situating atention deficit and hyperactivity in Portugal: social, historical, and ethical dimensions of an emerging global health issue]

Attention deficit and hyperactivity disorder (ADHD) is considered one of the most frequent behavioral and neurodevelopmental problems in school-age children and adolescents, both in Portugal and worldwide. The diagnostic categorization of ADHD and the prescription of psychostimulants as its first-line treatment have been the object not only of scientific research and clinical validation, but also of controversy and social critique, especially in light of the concept of medicalization. Despite its high profile and salience in such diverse fields as education, pharmaceuticals, mental health, and public policy, a significant gap remains in the characterization of social-historical, ethical, and institutional dimensions of ADHD outside English-speaking countries. Combining historical and ethnographic research with document and media analysis, the article addresses that challenge by tracing the social trajectory of ADHD in Portugal, from the emergence of "hyperactivity" in the 1970s and 1980s to the current public and political debates on psychostimulant treatments and prescribing trends. From this interdisciplinary perspective and based on the Portuguese case study, the aim of this article is to contextualize the definition, validation, and expansion of ADHD as part of a dynamic and socially situated process in which global diagnostic and pharmaceutical systems intersect with institutional and socioeconomic contingencies, as well as local specificities and needs. More broadly, the article discusses how the case study of ADHD contributes to the development of interdisciplinary research that helps rethinking the social scope of mental health across local and global health contexts.

The Association between Material Deprivation and Avoidable Mortality in Lisbon, Portugal

There is considerable evidence pointing to the existence of a socioeconomic gradient in mortality, which tends to be steeper in urban areas. Similar to other European cities, Lisbon is far from homogeneous since considerable geographical inequalities exist between the more advantaged and the more deprived neighborhoods. The main goals of this study are to describe the geographical pattern of premature deaths (before 65 years old), avoidable deaths (preventable and amenable to healthcare) and cause-specific mortality (HIV/AIDS and suicide) in Lisbon, at the lower administrative level (civil parish, in Portuguese: Freguesia), and analyze the statistical association between mortality risk and deprivation, before (1999–2003) and during the economic crisis (2008–2012). Smoothed Standardized Mortality Ratios (sSMR) and Relative Risk (RR) with 95% credible intervals were calculated to identify the association between mortality and deprivation. The analysis of the geographical distribution of cause-specific mortality reveals that civil parishes with high sSMR in the first period continued to present higher mortality rates in the second. Moreover, a significant statistical association was found between all the causes of death and deprivation, except suicide. These findings contribute to understanding how social conditions influence health outcomes and can offer insights about potential policy directions for local government.

Studying Healthcare Affordability during an Economic Recession: The Case of Greece

The significant deterioration of economic prosperity in Greece during the economic crisis decreased patients’ ability to pay. Thus, the objective of this study is to determine the factors affecting healthcare affordability in Greece during an economic recession. This study used data from the European Union Statistics on Income and Living Conditions (EU-SILC) 2016. The sample consisted of 18,255 households. Healthcare affordability was regressed on geographic characteristics as well as several variables that refer to the households’ financial condition. Region of residence, ability to make ends meet, and capacity to cope with unexpected financial expenses were found to be statistically significant. Using sample sizes of 1000 and 1096 adults, respectively, the European Quality of Life Surveys (EQLS) of 2007 and 2016 were also used as data sources. Economic crisis was expressed with a dummy variable: (1) 0: 2007, and (2) 1: 2016. Difficulty in responding to healthcare costs was regressed on survey year and several demographic, socioeconomic, and health characteristics, revealing that individuals were more likely to face difficulties in responding to healthcare costs during the economic crisis. These results confirm the mechanism on the basis of which economic crises affect healthcare access: primarily through the effects of demand-side barriers.

Disparities in emergency department use between Italians and migrants residing in Rome, Italy: the Rome Dynamic Longitudinal Study from 2005 to 2015

Background

The Emergency Department (ED) can be considered an indicator of accessibility and quality and can be influenced in period of economic downturns. In the last fifteen years, the number of migrants in Italy has doubled (from 2.4 million in 2005 to 5.2 in 2019, 4.1 and 8.7% of the total population, respectively). However, evidence about migrants’ healthcare use is poor, and no studies focused on the ED utilisation rate during the Great Recession are available. This study aims to analyse trends in all-cause and cause-specific ED utilisation among migrants and Italians residing in Rome, Italy, before and after 2008.

Methods

Longitudinal study based on data from the Municipal Register of Rome linked to the Emergency Department Register from 2005 to 2015. We analysed 2,184,467 individuals, aged 25–64 in each year. We applied a Hurdle model to estimate the propensity to use the ED and to model how often individuals accessed the ED.

Results

Migrants were less likely to be ED users than Italians, except for Africans (RR = 1.46, 95%CI 1.40–1.52) and Latin Americans (RR = 1.04, 95%CI 1.00–1.08) who had higher all-cause utilisation rates than non-migrants. Compared to the pre-2008 period, in the post-2008 we found an increase in the likelihood of being an ED user (OR = 1.34, 95%CI 1.34–1.35), and a decrease in ED utilisation rates (RR = 0.96, 95%CI 0.96–0.97) for the whole population, with differences among migrant subgroups, regardless of cause.

Conclusions

This study shows differences in the ED utilisation between migrants and Italians, and within the migrant population, during the Great Recession. The findings may reflect differentials in the health status, and barriers to access primary and secondary care among migrants. In this regard, health policies and cuts in health spending measures may have played a key role, and interventions to tackle health and access disparities should include policy measures addressing the underlying factors, adopting a Health in All Policies perspective. Further researches focusing on specific groups of migrants, and on the causes and diagnoses related to the ED utilisation, may help to explain the differences observed.

Socioeconomic inequalities in children's health-related quality of life according to weight status

OBJECTIVES

This study explores the association between socioeconomic position (SEP) and health-related quality of life (HRQoL) among Portuguese children according to their weight status.

METHODS

A total of 1215 primary school-aged children (mean age 8.78 years) from three Portuguese districts (Lisbon, Porto, Coimbra) were assessed during 2016/2017. Father and mother's education (low, medium, high) and work status (employed, unemployed/retired) were used as SEP indicators. Self-reported HRQoL was assessed with the KIDSCREEN-27. Height and weight were objectively measured and body mass index categorized in normal, overweight or obese. Age, sex, and district-adjusted linear regression models were fitted to estimate associations between SEP indicators and HRQoL dimensions, according to weight status.

RESULTS

We found that 24.9% of children were categorized as having overweight/obesity. The mean scores of the Physical Well-Being, and School Environment dimensions of HRQoL were lower among children classified with overweight/obesity compared to children with normal weight (57.21 vs 54.11, P < .001 and 57.85 vs 56.04, P = .010, respectively). Father's education was significantly associated with all HRQoL dimensions in children with a normal weight, but the same was not observed among children presenting overweight/obesity. An increase in the level of maternal education was also significantly associated with all HRQoL dimensions among children classified with a normal weight, and only for the School Environment dimension among children classified with overweight/obesity.

CONCLUSIONS

These results suggest the presence of socioeconomic inequalities in self-reported HRQoL from early age, particularly among children with normal weight.

Epidemiological Trend of Sepsis in Patients with Hospital Admissions Related to Hepatitis C in Spain (2000-2015): A Nationwide Study

Background: Hepatitis C virus (HCV) infection predisposes patients to other infectious diseases, such as sepsis. We aimed to analyze epidemiological trends of sepsis-related admissions, deaths, and costs in hospital admissions with chronic hepatitis C who had a hospital admission in Spain. Methods: We performed a retrospective study of all hospitalizations involving chronic hepatitis C in the Spanish Minimum Basic Data Set (MBDS) between 2000 and 2015. This period was divided into four calendar periods (2000–2004, 2005–2007, 2008–2011, and 2012–2015). Results: We selected 868,523 hospital admissions of patients with chronic hepatitis C over 16 years in the Spanish MBDS. Among them, we found 70,976 (8.17%) hospital admissions of patients who developed sepsis, of which 13,915 (19.61%) died during admission. We found an upward trend, from 2000–2003 to 2012–2015, in the rate of sepsis-related admission (from 6.18% to 10.64%; p < 0.001), the risk of sepsis-related admission (from 1.31 to 1.55; p < 0.001), and the sepsis-related cost per hospital admission (from 7198€ to above 9497€; p < 0.001). However, we found a downward trend during the same study period in the sepsis case-fatality rate (from 21.99% to 18.16%; p < 0.001), the risk of sepsis-related death (from 0.81 to 0.56; p < 0.001), and the length of hospital stay (LOHS) (from 16.9 to 13.9; p < 0.001). Moreover, the rate of bacterial Gram-positive and candidiasis infections decreased, while Gram-negative microorganisms increased from 2000–2003 to 2012–2015. Conclusions: Sepsis, in chronic hepatitis C patients admitted to the hospital, has increased the period 2000–2015 and has been an increasing burden for the Spanish public health system. However, there has also been a significant reduction in lethality and LOHS during the study period. In addition, the most prevalent specific microorganisms have also changed in this period.

How did the use of psychotropic drugs change during the Great Recession in Portugal? A follow-up to the National Mental Health Survey

BACKGROUND

Research suggests that economic recessions might be associated with a higher use of psychotropic drugs, but literature is scarce and contradictory in identifying the most vulnerable groups. This study aims to assess possible changes in the use of psychotropic drugs due to the economic recession in Portugal, by comparing self-reported consumption in 2008/09 and 2015/16.

METHODS

Data from the World Mental Health Survey Initiative Portugal (2008/09) and the National Mental Health Survey Follow-Up (2015/16) were used (n = 911). McNemar's tests were performed to estimate changes in consumption of any psychotropic drug and of antidepressants, anxiolytics, and hypnotics/sedatives. Multiple Generalised Estimating Equations models with interaction effects were used to estimate the population odds of consuming psychotropic drugs according to year, gender and age.

RESULTS

An increase of 6.74% was estimated in the consumption of psychotropic drugs from 2008/09 to 2015/16. Population odds of consuming any psychotropic drugs in 2015/16 were estimated to be 1.5 times higher than in 2008/09 (OR = 1.50;95%CI:1.13-2.01), particularly for hypnotics/sedatives (OR = 1.60;95%CI:1.14-2.25). Women and older individuals presented higher odds of consuming any psychotropic drugs (OR = 2.79;95%CI:2.03-3.84, and OR = 1.80;95%CI:1.28-2.54), after adjusting for year of assessment and education. However, when evaluating the interaction effect of the year with gender and age, men and younger individuals reported higher odds of consuming any psychotropic drugs in 2015/16, when compared to 2008/09 (OR = 1.85;95%CI:1.08-3.17, and OR = 1.95;95%CI:1.32-2.90, respectively).

CONCLUSIONS

The findings indicate that the period of economic recession was associated with an increased risk of psychotropic drugs use in Portugal. Consumption of psychotropic drugs remained higher among women and older individuals, but the results suggest that the economic crisis had a disproportionate impact on men and younger individuals. This identification of the most vulnerable population groups is useful to design effective and targeted public health interventions aimed at alleviating the effects of economic recessions.

Epidemiological trend of hepatitis C-related liver events in Spain (2000-2015): A nationwide population-based study

OBJECTIVE

Analysis the epidemiological trends of hospital admissions, intra-hospital deaths, and costs related to chronic hepatitis C (CHC) taking into account four major clinical stages [compensated cirrhosis (CC), end-stage liver disease (ESLD), hepatocellular carcinoma (HCC), and liver transplantation (LT)] in Spain.

METHODS

Retrospective study in patients with chronic hepatitis C and a hospital admission in the Spanish Minimum Basic Data Set from 2000 to 2015. Outcome variables were admission, death, length of hospital stay and costs.

RESULTS

A total of 868,523 hospital admissions with CHC (25.5% CC, 25.3% ESLD, 8.6% HCC, and 2.5% LT) were identified. Overall rates of admission and mortality increased from 2000-2003 to 2004-2007, but after 2008, these rates stabilized and/or decreased. An upward trend was found for hospitalization percentage in CC (from 22.3% to 30%; p < 0.001), ESLD (from 23.9% to 27.1%; p < 0.001), HCC (from 7.4% to 11%; p < 0.001), and LT (from 0.07% to 0.10%; p = 0.003). An upward trend was also found for case fatality rate, except in ESLD (p = 0.944). Gender and age influenced the evolution of hospitalization rates and mortality differently. The length of hospital stay showed a significant downward trend in all strata analyzed (p < 0.001). Cost per patient had a significant upward trend (p < 0.001), except in LT, and a decrease from 2008-2011 to 2012-2015 in CC (p = 0.025), HCC (p < 0.001), and LT (p = 0.050) was found.

CONCLUSION

The initial upward trend of the disease burden in CHC has changed from 2000 to 2015 in Spain, improving in many parameters after 2004-2007, particularly in the 2012-2015 calendar period.

'If there were doctors who could understand our problems, I would already be better': dissatisfactory health care and marginalisation in superdiverse neighbourhoods

How people in community settings describe their experience of disappointing health care, and their responses to such dissatisfaction, sheds light on the role of marginalisation and underlines the need for radically responsive service provision. Making the case for studying unprompted accounts of dissatisfaction with healthcare provision, this is an original analysis of 71 semi-structured interviews with healthcare users in superdiverse neighbourhoods in four European cities. Healthcare users spontaneously express disappointment with services that dismiss their concerns and fail to attend to their priorities. Analysing characteristics of these healthcare users show that no single aspect of marginalisation shapes the expression of disappointment. In response to disappointing health care, users sought out alternative services and to persuade reluctant service providers, and they withdrew from services, in order to access more suitable health care and to achieve personal vindication. Promoting normative quality standards for diverse and diversifying populations that access care from a range of public and private service providers is in tension with prioritising services that are responsive to individual priorities. Without an effort towards radically responsive service provision, the ideal of universal access on the basis of need gives way to normative service provision.

Austerity, healthcare provision, and health outcomes in Spain

The recession that started in the United States in December 2007 has had a significant impact on the Spanish economy through a large increase in the unemployment rate and a long recession which led to tough austerity measures imposed on public finances. Taking advantage of this quasi-natural experiment, we use data from the Spanish Ministry of Health from 1996 to 2015 to provide novel causal evidence on the short-term impact of changes in healthcare provision and regulations on health outcomes. The fact that regional governments have discretionary powers in deciding healthcare budgets and that austerity measures have not been implemented uniformly across Spain helps isolate the impact of these policy changes on health indicators of the Spanish population. Using Ruhm's (Q J Econ 115(2):617-650, 2000) fixed effects model, we find that medical staff and hospital bed reductions account for a significant increase in mortality rates from circulatory diseases and external causes, but not from other causes of death. Similarly, mortality rates do not seem to be robustly affected by the 2012 changes in retirees' pharmaceutical co-payments and access restrictions for illegal immigrants. Our results are robust to changes in model specification and sample selection and are primarily driven by accidental and emergency deaths rather than in-hospital mortality, which suggests a larger role for decreases in accessibility rather than decreases in healthcare quality as impact channels.

Barriers to mental health services utilisation in Portugal - results from the National Mental Health Survey

Background: The treatment gap for mental disorders remains a challenge worldwide. Identifying reasons for nontreatment may contribute to reducing this gap.Aims: To evaluate sociodemographic and clinical factors associated with use and barriers to treatment in Portugal.Method: Data from the 2009 National Mental Health Survey were used. Participants reported 12-month treatment and reasons for nontreatment. Logistic regression models analysed the association between sociodemographic (education; employment; income; marital status) and clinical variables (mental disorder diagnosis; disability) with treatment and type of barriers (low perceived need; structural; attitudinal).Results: The majority of participants with a mental disorder was not treated. Treatment was more common among participants with mood disorders (OR = 4.19; 95% CI: 2.72-6.46), and disability (OR = 2.43; 95% CI: 1.33-4.46), and less common among single participants (OR = 0.38; 95% CI: 0.20-0.70) and those with basic/secondary education (OR = 0.42; 95% CI: 0.24-0.73). Attitudinal barriers were more likely among participants with none/primary (OR = 2.90; 95% CI: 1.42-5.90) and basic/secondary education (OR = 1.70; 95% CI: 1.01-2.85), and less likely among those with substance use disorders (OR = 0.27; 95% CI: 0.10-0.70). Low perceived need was higher among single people (OR = 1.77; 95% CI: 1.01-3.08), and lower among those with anxiety (OR = 0.50; 95% CI: 0.28-0.90) and mood disorders (OR = 0.16; 95% CI: 0.09-0.30). Unemployed participants had higher odds of reporting structural barriers (OR = 3.76; 95% CI: 1.29-10.92).Conclusions: This study identifies factors associated with nontreatment, providing useful evidence to develop policies and effective interventions.

Unintended consequences of expenditure targets on resource allocation in health systems

In recent decades, several countries have reformed their health care systems leading to the devolution of power to a lower governance level and, subsequently, to re-centralisation. Due to the ambiguous results of these policies and the start of the financial crisis of 2008, a wide number of national governments implemented cutback initiatives aimed at controlling health expenditure. The literature shows that the introduction of such initiatives may have produced unintended consequences on health systems' performance. In order to better understand the power relations and the resulting decision-making processes between national governments and local authorities, it is important to focus on the effects of such expenditure control mechanisms on the inputs of the health systems, i.e. the production factors. This research aims at investigating the effects of a cutback initiative intended to control personnel costs in a federal Beveridge health system through the analysis of resource allocation at the devolved level. The paper is based on a quantitative analysis of data resulting from the financial statements published by the 21 Italian regional health systems from 2012 to 2017. The results show that, although the Italian regional health systems managed to reduce personnel costs - i.e. hitting the target - the control of the total cost dynamic was not fully addressed. Overall, the initiative implemented by the national government had the effect of limiting the decision-making autonomy of regional authorities, pushing them toward shifting resource allocation from personnel to the purchase of services.

[Access to healthcare in Portugal in the wake of the crisis. Not everything is money?]

Unmet healthcare needs have been used to assess access to healthcare. In scenarios of recession and financial constraints on public policies, it is important to identify which factors besides income can be used to mitigate barriers to access. This was the focus of our study on Portugal's case in the wake of the crisis. We used 17,698 observations from the 5th National Health Survey (2014). We analyzed self-reported unmet needs for medical appointments and treatments, dental healthcare, and prescribed medications. We used a bivariate selection model, considering the fact that unmet needs could only be observed in the subsample of individuals that felt the need for healthcare. The risk of unmet needs for healthcare decreased in individuals with higher income and schooling levels and in the elderly and men. Exclusive coverage by the National Health Service increased the risk of unmet dental healthcare needs. The absence of a circle of close friends to whom one can ask for help and lack of trust in others increased the likelihood of unmet healthcare needs. Better health decreased the risk of unmet needs. While income is an important predictor of unmet needs, we found the impact of other factors such as gender, age, and education. Participation in informal groups reduced the likelihood of unmet needs. Individuals with more healthcare needs end up suffering additional risk.

Disability and common mental disorders: Results from the World Mental Health Survey Initiative Portugal

Background

Common mental disorders are highly prevalent and disabling, leading to substantial individual and societal costs. This study aims to characterize the association between disability and common mental disorders in Portugal, using epidemiological data from the World Mental Health Survey Initiative.

Methods

Twelve-month common mental disorders were assessed with the CIDI 3.0. Disability was evaluated with the modified WMHS WHODAS-II. Logistic regression models were used to assess the association between disability and each disorder or diagnostic category (mood or anxiety disorders).

Results

Among people with a common mental disorder, 14.6% reported disability. The specific diagnoses significantly associated with disability were post-traumatic stress disorder (OR: 6.69; 95% CI: 3.20, 14.01), major depressive disorder (OR: 3.49; 95% CI: 2.13, 5.72), bipolar disorder (OR: 3.41; 95% CI: 1.04, 11.12) and generalized anxiety disorder (OR: 3.14; 95% CI: 1.43, 6.90). Both categories of anxiety and mood disorders were significantly associated with disability (OR: 1.88; 95% CI: 1.23, 2.86 and OR: 3.94; 95% CI: 2.45, 6.34 respectively).

Conclusions

The results of this study add to the current knowledge in this area by assessing the disability associated with common mental disorders using a multi-dimensional instrument, which may contribute to mental health policy efforts in the development of interventions to reduce the burden of disability associated with common mental disorders.

Changes in socioeconomic position among individuals with mental disorders during the economic recession in Portugal: a follow-up of the National Mental Health Survey

AIMS

Portugal was one of the European countries most affected by the period of economic recession initiated in 2008. Social inequalities are likely to widen during such periods and disproportionately affect people with mental disorders. The present study aims to compare self-reported changes in indicators of socioeconomic position during the economic recession in Portugal among people with and without mental disorders in the beginning of this period. Three dimensions were assessed, namely employment situation, experiences of financial hardship and subjective social status.

METHODS

Data from the World Mental Health Survey Initiative Portugal (2008/2009) and from the National Mental Health Survey Follow-up (2015/2016) were used (n = 911). Multinomial and logistic recession models were performed to examine the association between the presence of any 12-month mood or anxiety mental disorder in 2008/2009 and indicators of socioeconomic position in 2015/2016. All analyses were adjusted for gender, age, presence of any physical disorder and education at the baseline.

RESULTS

Participants that had any mental disorder in the beginning of the economic recession reported 2.20 (95% CI 1.31-3.71; P < 0.01) higher odds of financial hardship related to daily life in 2015/2016, when compared with those without any mental disorder, after adjusting for age, gender, education and presence of any physical disorder. The results may also suggest a pattern of increased socioeconomic disadvantage among people with prior mental disorder, despite not reaching statistical significance.

CONCLUSIONS

The results of this study suggest that the economic recession may have contributed to wider social inequalities between people with and without mental disorders. Policies to support these individuals, such as access to treatment and alleviation of financial hardship, should be a priority in times of economic downturn.

Solutions to tackle the mental health consequences of the economic recession: A qualitative study integrating primary health care users and professionals' perspectives

This qualitative study explores solutions proposed by primary health care users and professionals to address the consequences of the economic recession and austerity measures on populations' mental health and delivery of care in Portugal. Qualitative data were collected in three primary health care centres in the Lisbon Metropolitan Area. Five focus groups with 26 users and semistructured interviews with 27 health professionals were conducted. Interviews were audio-recorded, transcribed verbatim and underwent thematic analysis. Solutions proposed by users focused on improvements in accessibility and management of services, socioeconomic and living conditions, human resources for health, and investment in mental health. Health professionals focused on improvements in integration and articulation of services, infrastructure and structural barriers to primary care, recruitment and retention of human resources, and socioeconomic and living conditions. The themes from both groups were integrated and organized into three axes for action: 1) increasing investment and reversing austerity measures in health and social sectors; 2) coordination and integration of mental health care; and 3) tackling the social determinants of mental health. The findings provide an assessment of the needs and priorities set by primary health care users and professionals, reflecting their contextspecific experiences. These complementary perspectives highlight the need for inter-sectoral efforts in policy-making to improve delivery of care and to mitigate social inequalities in health across the Portuguese population.

Moral Distress and Austerity: An Avoidable Ethical Challenge in Healthcare

Austerity, by its very nature, imposes constraints by limiting the options for action available to us because certain courses of action are too costly or insufficiently cost effective. In the context of healthcare, the constraints imposed by austerity come in various forms; ranging from the availability of certain treatments being reduced or withdrawn completely, to reductions in staffing that mean healthcare professionals must ration the time they make available to each patient. As austerity has taken hold, across the United Kingdom and Europe, it is important to consider the wider effects of the constraints that it imposes in healthcare. Within this paper, we focus specifically on one theorised effect-moral distress. We differentiate between avoidable and unavoidable ethical challenges within healthcare and argue that austerity creates additional avoidable ethical problems that exacerbate clinicians' moral distress. We suggest that moral resilience is a suitable response to clinician moral distress caused by unavoidable ethical challenges but additional responses are required to address those that are created due to austerity. We encourage clinicians to engage in critical resilience and activism to address problems created by austerity and we highlight the responsibility of institutions to support healthcare professionals in such challenging times.

Excess winter mortality and morbidity before, during, and after the Great Recession: the Portuguese case

Although winter mortality and morbidity are phenomena common to most European countries, their magnitude varies significantly from country to country. The geographical disparities among regions with similar climates are the result of several social, economic, demographic, and biological conditions that influence an individual's vulnerability to winter conditions. The impact of poor socioeconomic conditions may be of such magnitude that an economic recession may aggravate the seasonal mortality pattern. This paper aims to measure the seasonal winter mortality, morbidity, and their related costs during the Great Recession (2009-2012) in mainland Portugal and its Regional Health Administrations (RHAs) and to compare it with the periods preceding and following it. Monthly mortality and morbidity data were collected and clustered into three periods: Great Recession (2009-2012), Pre-Recession (2005-2008), and Post-Recession (2013-2016). The impact of seasonal winter mortality and morbidity during the Great Recession in Portugal and its Regional Health Administrations was measured through the assessment of age-standardized excess winter (EW) death and hospital admissions rate and index, expected life expectancy gains without EW deaths, EW rate of potential years of life lost, and EW rate of emergency hospital admission costs. Important increases of winter deaths and hospital admissions were identified, resulting in an important number of potential years of life lost (87 years of life lost per 100,000 inhabitants in 2009-2012), life expectancy loss (1 year in 2009-2012), and National Health Service costs with explicit temporal and spatial variations. These human and economic costs have decreased consistently during the analyzed periods, while no significant increase was found during the Great Recession. Despite its reduction, the winter excess morbidity and mortality highlight that Portugal still faces substantial challenges related to a highly vulnerable population, calling for investments in better social and health protection.

Trends in sociodemographic and health care factors in Portuguese and non-Portuguese mothers giving birth in Portugal, 1995-2014

BACKGROUND

Time-trend disparity in adverse pregnancy outcomes according to maternal nationality or immigration status has been well documented. In this study, we investigated time changes in individual-level risk factors for adverse pregnancy outcomes that have not been given the needed attention.

OBJECTIVE

To compare 20-year trends in sociodemographic, obstetric, health care factors, and adverse pregnancy outcomes in Portuguese and non-Portuguese women.

METHODS

We studied 2 105 497 livebirths from Portuguese national birth registry (1995-2014). We compared maternal sociodemographic characteristics (age, education, employment, and marital status), obstetric, and health care factors (parity, number of foetuses, place and type of delivery) in Portuguese and non-Portuguese at four periods (1995-1999, 2000-2004, 2005-09, and 2010-2014). Time-trend analysis using joinpoint regression method was performed to identify trends (joinpoints) and compare time changes in the prevalence of sociodemographic, obstetric, and health care factors expressed as annual percentage change (APC).

RESULTS

The proportion of livebirths in non-Portuguese mothers increased between 1995 and 1999 (2.9%), 2000-2004 (6.3%), 2005-2009 (9.5%), and 2010-2014 (9.8%). The proportion of women aged ≥ 35 years among Portuguese mothers varied from 11.1% (1995-1999), 14.4% (2000-2004), 18.6% (2005-2009) to 25.5% (2010-2014); among non-Portuguese women, the corresponding proportions were 15.7% (1995-1999), 14.6% (2000-2004), 16.1% (2005-2009), and 19.0% (2010-2014), respectively. The rate of change in maternal age ≥ 35 years had 2 joinpoints in both Portuguese (APC = 6.5%, 95% confidence interval [CI] 6.2, 6.9; 2005-2014) and non-Portuguese (3.3%, 95% CI 2.5, 4.0; 2002-2014). Increase in caesarean rate was higher for non-Portuguese (24.0%-36.1%) than the Portuguese (30.6%-31.6%) between 1995 and 2014.

CONCLUSIONS

Sociodemographic, obstetric, and health care factors have divergent time trends and rate of change for Portuguese and non-Portuguese.

HIV/AIDS length of stay in Portugal under financial constraints: a longitudinal study for public hospitals, 2009-2014

BACKGROUND

The global financial crisis and the economic and financial adjustment programme (EFAP) forced the Portuguese government to adopt austerity measures, which also included the health sector. The aim of this study was to analyse factors associated with HIV/AIDS patients' length of stay (LOS) among Portuguese hospitals, and the potential impact of the EFAP measures on hospitalizations among HIV/AIDS patients.

METHODS

Data used in this analysis were collected from the Portuguese database of Diagnosis Related Groups (DRG). We considered only discharges classified under MCD 24 created for patients with HIV infection. A total of 20,361 hospitalizations occurring between 2009 and 2014 in 41 public hospitals were included in the analysis. The outcome was the number of days between hospital admission and discharge dates (LOS). Hierarchical Poisson regression model with random effects was used to analyse the relation between LOS and patient, treatment and setting characteristics. To more effectively analyse the impact of the EFAP implementation on HIV/AIDS hospitalizations, yearly variables, as well as a variable measuring hospitals' financial situation (current ratio) was included.

RESULTS

For the 5% level, having HIV/AIDS as the principal diagnosis, the number of secondary diagnoses, the number of procedures, and having tuberculosis have a positive impact in HIV/AIDS LOS; while being female, urgent admission, in-hospital mortality, pneumocystis pneumonia, hepatitis C, and hospital's current ratio contribute to the decrease of LOS. Additionally, LOS between 2010 and 2014 was significantly shorter in comparison to 2009. Differences in LOS across hospitals are significant after controlling for these variables.

CONCLUSION

Following the EFAP, a number of cost-containment measures in the health sector were implemented. Results from our analysis suggest that the implementation of these measures contributed to a significant decrease is LOS among HIV/AIDS patients in Portuguese hospitals.

Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil

BACKGROUND

Brazil's Estratégia Saúde da Família (ESF) is one of the largest and most robustly evaluated primary healthcare programmes of the world, but it could be affected by fiscal austerity measures and by the possible end of the Mais Médicos programme (MMP)-a major intervention to increase primary care doctors in underserved areas. We forecast the impact of alternative scenarios of ESF coverage changes on under-70 mortality from ambulatory care-sensitive conditions (ACSCs) until 2030, the date for achievement of the Sustainable Development Goals (SDGs).

METHOD

A synthetic cohort of 5507 Brazilian municipalities was created for the period 2017-2030. A municipal-level microsimulation model was developed and validated using longitudinal data and estimates from a previous retrospective study evaluating the effects of municipal ESF coverage on mortality rates. Reductions in ESF coverage, and its effects on ACSC mortality, were forecast based on two probable austerity scenarios, compared with the maintenance of the current coverage or the expansion to 100%. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, healthcare-related variables, and programme duration effects.

RESULTS

Under austerity scenarios of decreasing ESF coverage with and without the MMP termination, mean ACSC mortality rates would be 8.60% (95% CI 7.03-10.21%; 48,546 excess premature/under-70 deaths along 2017-2030) and 5.80% (95% CI 4.23-7.35%; 27,685 excess premature deaths) higher respectively in 2030 compared to maintaining the current ESF coverage. Comparing decreasing ESF coverage and MMP termination with achieving 100% ESF coverage (Universal Health Coverage scenario) in 2030, mortality rates would be 11.12% higher (95% CI 9.47-12.76%; 83,937 premature deaths). Reductions in ESF coverage would have stronger effects on mortality from infectious diseases and nutritional deficiencies and would disproportionately impact poorer municipalities, with the concentration index for ACSC mortality 11.77% higher (95% CI 0.31-22.32%) and also ending historical declines in racial health inequalities between white and black/pardo Brazilians.

CONCLUSIONS

Reductions in primary healthcare coverage due to austerity measures are likely to be responsible for many avoidable deaths and may preclude achievement of SDGs for health and inequality in Brazil and in other low- and middle-income countries.

Exploring socioeconomic and mental health trajectories during times of economic recession: a qualitative study with primary health care users and professionals

Background: The 2008 economic recession has been shown to affect populations' mental health due to deterioration of socioeconomic and living conditions. Concurrently, mental health problems may have constituted a vulnerability to wider social inequalities during this period.Aims: To explore perceptions and experiences of primary health care users and professionals regarding the relationship between mental health and socioeconomic position during the economic recession in Portugal.Method: Data were collected in three primary health care centres in Lisbon Metropolitan Area. Focus groups and semi-structured interviews were conducted with users and professionals, respectively. Interviews were audio-recorded, transcribed verbatim and underwent thematic analysis.Results: Two themes were obtained. The first comprised the relationship between changes in socioeconomic conditions (unemployment, precarious work conditions and financial hardship) and poor mental health. The second involved the consequences of experiencing mental health problems during the recession, namely disability, need of sick leave and early retirement.Conclusions: This study provided a comprehensive overview of the bidirectional relationship between socioeconomic conditions and mental health, emphasizing the need to develop policies to address the drivers of poor mental health during times of economic downturn and tackle the barriers faced by people with mental disorders to promote their full social inclusion.