Structural adjustment and health: A conceptual framework and evidence on pathways

The Impact of Social Expenditure on Sustainable Human Development: Empirical Evidence on the Suicide Deaths in a Developing Country

Suicide has been a serious international public mental health problem and is one of the top twenty leading causes of death worldwide. This study aims to investigate the impact of social expenditure on suicide deaths in Turkiye as a developing country from 1982 to 2019. The Bounds Testing Approach to Cointegration and Autoregressive Distributed Lag (ARDL) methods were used. The results indicated that social expenditure has a statistically significant and negative effect on total suicide and female suicide deaths, but it has a statistically insignificant and negative impact on male suicide death. The contribution of this study is to examine for the first time whether social expenditure has an impact on total, female, and male suicide mortality in Turkiye. Policymakers should regard increasing social spending in the government budget to prevent suicide deaths in Turkiye.

Performance measurement of Brazilian federal university hospitals: an overview of the public health care services through principal component analysis

PURPOSE

This paper aimed to contextualize the process of public hospital providing services, based on the measurement of the performance of Federal University Hospitals (HUFs) of Brazil, using the technique of multivariate statistics of principal component analysis.

DESIGN/METHODOLOGY/APPROACH

This research presented a descriptive and quantitative character, as well as exploratory purpose and followed the inductive logic, being empirically structured in two stages, that is, the application of principal component analysis (PCA) in four healthcare performance dimensions; subsequently, the full reapplication of principal component analysis in the most highly correlated variables, in module, with the first three main components (PC1, PC2 and PC3).

FINDINGS

From the principal component analysis, considering mainly component I, with twice the explanatory power of the second (PC2) and third components (PC3), it was possible to evidence the efficient or inefficient behavior of the HUFs evaluated through the production of medical residency, by specialty area. Finally, it was observed that the formation of two groups composed of seven and eight hospitals, that is, Groups II and IV shows that these groups reflect similarities with respect to the scores and importance of the variables for both hospitals' groups.

RESEARCH LIMITATIONS/IMPLICATIONS

Among the main limitations it was observed that there was incomplete data for some HUFs, which made it impossible to search for information to explain and better contextualize certain aspects. More specifically, a limited number of hospitals with complete information were dealt with for 60% of SIMEC/REHUF performance indicators.

PRACTICAL IMPLICATIONS

The use of PCA multivariate technique was of great contribution to the contextualization of the performance and productivity of homogeneous and autonomous units represented by the hospitals. It was possible to generate a large quantity of information in order to contribute with assumptions to complement the decision-making processes in these organizations.

SOCIAL IMPLICATIONS

Development of public policies with emphasis on hospitals linked to teaching centers represented by university hospitals. This also involved the projection of improvements in the reach of the efficiency of the services of assistance to the public health, from the qualified formation of professionals, both to academy, as to clinical practice.

ORIGINALITY/VALUE

The originality of this paper for the scenarios of the Brazilian public health sector and academic area involved the application of a consolidated performance analysis technique, that is, PCA, obtaining a rich work in relation to the extensive exploitation of techniques to support decision-making processes. In addition, the sequence and the way in which the content, formed by object of study and techniques, has been organized, generates a particular scenario for the measurement of performance in hospital organizations.

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.

Utilization of Health Care Services and Accessibility Challenges among Adults Aged 50+ before and after Austerity Measures across 27 European Countries: Secular Trends in the SHARE Study from 2004/05 to 2019/20

This study aimed to assess and compare the utilization of preventive and other health services and the cost or availability in different regions of Europe, before and during the economic crisis. The data used in the study were obtained from Wave 8 of the Survey of Health, Ageing and Retirement in Europe (2019/2020) and Wave 1 data (2004/5), with a sample size of 46,106 individuals aged ≥50 across 27 countries, adjusted to represent a population of N = 180,886,962. Composite scores were derived for preventive health services utilization (PHSU), health care services utilization (HCSU), and lack of accessibility/availability in health care services (LAAHCS). Southern countries had lower utilization of preventive services and higher utilization of other health services compared to northern countries, with a significant lack of convergence. Moreover, the utilization of preventive health services decreased, whereas the utilization of secondary care services increased during the austerity period. Southern European countries had a significantly higher prevalence of lack of accessibility. An increase in the frequency of lack of accessibility/availability in health care services was observed from 2004/5 to 2019/20. In conclusion, our findings suggest that health inequalities increase during crisis periods. Therefore, policy interventions could prioritize accessibility and expand health coverage and prevention services.

Predictors of Unmet Healthcare Needs during Economic and Health Crisis in Greece

(1) Background: The aim of this study was to identify predictors of the unmet healthcare needs during the financial and recent health crisis in Greece. (2) Methods: Time series analysis was performed for the years 2008 through 2022 using the Eurostat database. The dependent variable was the percentage of people who reported unmet need for medical care. Demographic, socioeconomic, and health data, as well as health expenditures, were used as independent variables. Correlation analysis and simple linear regression models were conducted to analyze the results. (3) Results: Unmet health needs in Greece increased from the start of the crisis until 2016, as a gradual de-escalation of the crisis was observed. However, in 2019 the country recorded the second highest level of unmet needs for medical care before the health crisis. Limitations in usual activities, reporting bad/very bad health status, being unemployed, and having low income increased the likelihood of unmet needs. Health expenditures (public or private) were also significant determinants of unmet healthcare needs. (4) Conclusions: The increased unmet health needs widen inequalities in health and healthcare access. Therefore, health policies should eliminate barriers which restrict the access to health and enhance healthcare services, developing conditions for citizens' well-being.

Envisioning environmental equity: climate change, health, and racial justice

Climate change has a broad range of health impacts and tackling climate change could be the greatest opportunity for improving global health this century. Yet conversations on climate change and health are often incomplete, giving little attention to structural discrimination and the need for racial justice. Racism kills, and climate change kills. Together, racism and climate change interact and have disproportionate effects on the lives of minoritised people both within countries and between the Global North and the Global South. This paper has three main aims. First, to survey the literature on the unequal health impacts of climate change due to racism, xenophobia, and discrimination through a scoping review. We found that racially minoritised groups, migrants, and Indigenous communities face a disproportionate burden of illness and mortality due to climate change in different contexts. Second, this paper aims to highlight inequalities in responsibility for climate change and the effects thereof. A geographical visualisation of responsibility for climate change and projected mortality and disease risk attributable to climate change per 100 000 people in 2050 was conducted. These maps visualise the disproportionate burden of illness and mortality due to climate change faced by the Global South. Our third aim is to highlight the pathways through which climate change, discrimination, and health interact in most affected areas. Case studies, testimony, and policy analysis drawn from multidisciplinary perspectives are presented throughout the paper to elucidate these pathways. The health community must urgently examine and repair the structural discrimination that drives the unequal impacts of climate change to achieve rapid and equitable action.

Global financing for health policy and systems research: a review of funding opportunities

Health policy and systems research (HPSR) is a neglected area in global health financing. Despite repeated calls for greater investment, it seems that there has been little growth. We analysed trends in reported funding and activity between 2015 and 2021 using a novel real-time source of global health data, the Devex.com database, the world's largest source of funding opportunities related to international development. We performed a systematic search of the Devex.com database for HPSR-related terms with a focus on low- and middle-income countries. We included 'programs', 'tenders & grants' and 'contract awards', covering all call statuses (open, closed or forecast). Such funding opportunities were included if they were related specifically to HPSR funding or had an HPSR component; pure biomedical funding was excluded. Our findings reveal a relative neglect of HPSR, as only ∼2% of all global health funding calls included a discernible HPSR component. Despite increases in funding calls until 2019, this situation reversed in 2020, likely reflecting the redirection of resources to rapid assessments of the impacts of the coronavirus disease 2019 (COVID-19) pandemic. Most identified projects represented small-scale opportunities-commonly for consultancies or technical assistance. To the extent that new data were generated, these projects were either tied to a specific large intervention or were narrow in scope to meet a specific challenge-with many examples informing policy responses to the Covid-19 pandemic. Nearly half of advertised funding opportunities were multi-country projects, usually addressing global policy priorities like health systems strengthening or development of coordinated public health policies at a regional level. The Covid-19 pandemic has shown why investing in HPSR is more important than ever to enable the delivery of effective health interventions and avoid costly implementation failures. The evidence presented here highlights the need to scale up efforts to convince global health funders to institutionalize the inclusion of HPSR components in all funding calls.

The return of austerity imperils global health

Recognising the world's lack of preparedness for the COVID-19 pandemic, international organisations like the World Health Organization, World Bank, and International Monetary Fund are calling for extensive additional funding to strengthen pandemic preparedness and response systems in low-income and middle-income countries, including through domestic resource mobilisation. This article examines the prospects of national health budgets increasing in such a context, drawing on new International Monetary Fund projections on public spending around the world. We show that by 2024 public spending will be lower than the 2010s average for almost half of all low-income and middle-income countries. A key driver of this new wave of austerity is the dramatic increase in public spending dedicated to repaying external debt-underpinned by growing debt stocks, US interest rates rises, and commodity price hikes. As in earlier crises, the stage is set for a situation where population health deteriorates-via compound effects of the pandemic and widespread economic hardship-while public health services required to tackle increased need are facing steep cuts. We conclude by considering what can be done to avoid repeating the mistakes of the past.

Decolonising the global to local movement: Time for a new paradigm

Mama Amaan Project (MAP) delivered perinatal education and doula services to underserved refugee and immigrant communities in Seattle, Washington. MAP presented at a 'global to local (glocal)' workshop for US-based global health agencies redirecting their experience and resources to address domestic health crises. Glocal models reference Global South anti-colonial social transformations through Primary Health Care (PHC) - 'health for all as a right' and investment in strong public sectors. As Black women working in our communities, we resisted labelling MAP glocal. Western donors and NGOs appropriate PHC's community participation narratives, meanwhile implementing World Bank/IMF economic structural adjustment health system cuts - thereby shifting austerity-related resource shortfalls to communities. In US contexts of neoliberal shrinking social safety nets and workers' rights, similar strategies to address austerity-related health disparities are promoted as 'global to local'. Projects like MAP cannot substitute quality public services. They expose gaps and build community empowerment to demand quality healthcare. Drawing on MAP and 'global health' experience in Mozambique, we call for re-embracing PHC's activist values - agitating for health as a universal human right for all, rather than putting the burden and blame on underserved communities. We propose decolonising the 'glocal' paradigm by embracing 'transnationality', 'relationality' and 'mutuality'.

Structural adjustment programmes and infectious disease mortality

International financial organisations like the International Monetary Fund (IMF) play a central role in shaping the developmental trajectories of fiscally distressed countries through their conditional lending schemes, known as ‘structural adjustment programmes’. These programmes entail wide-ranging domestic policy reforms that influence local health and welfare systems. Using novel panel data from 187 countries between 1990 and 2017 and an instrumental variable technique, we find that IMF programmes lead to over 70 excess deaths from respiratory diseases and tuberculosis per 100,000 population and that IMF-mandated privatisation reforms lead to over 90 excess deaths per 100,000 population. Thus structural adjustment programmes, as currently designed and implemented, are harmful to population health and increase global infectious disease burdens.

A 'whole of United Nations approach' to tackle antimicrobial resistance? A mapping of the mandate and activities of international organisations

The 2015 World Health Organization Global Action Plan and other international policy documents have stressed the need for a 'whole of United Nations approach' in addressing antimicrobial resistance (AMR). As several years have passed, the goal of this paper is to take stock of the current role, mandate, and activities of international organisations and other global stakeholders on AMR. Relevant information is identified through a web-based search and a review of policy documents from international organisations. Based on the assessment of 78 organisations, 21 have AMR-specific activities in the broader sense, although for many of these organisations, their involvement is limited in scope, and 36 have AMR-sensitive activities reflecting the wide scope of AMR. An interdisciplinary framework based on six relevant challenges of global collective actions regarding AMR as well as the main functions of international organisations in global governance is used to organise the findings into several 'clusters'. AMR is not a priority for many international organisations, but some of them can leverage current efforts to tackle AMR while contributing to their core agenda. Overall, a 'whole of UN approach' to AMR within the framework of Sustainable Development Goals is critical to move the global governance of AMR forward.

When Coffee Collapsed: An Economic History of HIV in Uganda

In some Ugandan fishing communities, almost half the population lives with HIV. Researchers designate these communities "HIV hotspots" and attribute disproportionate disease burdens to "sex-for-fish" relationships endemic to the lakeshores. In this article, we trace the emergence of Uganda's HIV hotspots to structural adjustment. We show how global economic policies negotiated in the 1990s precipitated the collapse of Uganda's coffee sector, causing mass economic dislocation among women workers, who migrated to the lake. There, they entered overt forms of sex work or marriages they may have otherwise avoided, intimate economic arrangements that helped to "engineer the spread of HIV," as one respondent recounted.

Factors Associated With Coverage of Health Insurance Among Women in Malawi

Introduction

Access to healthcare for the vulnerable groups including women has long been a theme encouraged worldwide from the first general assembly on health to the current sustainable development goals. Despite many countries having a free public healthcare system, there are inequalities in access to care and significant out-of-pocket spending, pushing most women into poverty against the principles of universal health coverage. Coverage of Malawian women with health insurance is poor; thus, there is limited cushioning and high risk of poverty, as women bear costs of care as primary caregivers. There is need to explore determinants of coverage of health insurance among women in Malawi to inform health policy.

Methodology

This study was quantitative in nature, using cross-sectional secondary data from the 2015 to 2016 Malawi Demographic and Health Survey involving women aged between 15 and 49 years. We assessed factors associated with insurance coverage by comparing women with and without insurance schemes using binary logistic regression. Analysis was done using STATA statistical package version 13.

Results

The analysis included a total of 24,562 women with a mean age of 28 SD (9.3). Of these cases, 1.5% had health insurance. High education attainment, occupation, and wealth were significantly associated with health insurance ownership, with all having p-values of < 0.01. On the other hand, a woman's residence, marital status, and who heads a household were not associated with ownership of health insurance significantly.

Conclusion

Education, occupation, and wealth have a key role in influencing a woman's choice in owning health insurance. This informs policymakers and health insurance providers on how best to approach women's health financing and factors to target in social security programs and health insurance products that speak to women's needs and capacity.

The impact of economic recessions on health workers: a systematic review and best-fit framework synthesis of the evidence from the last 50 years

Economic crises carry a substantial impact on population health and health systems, but little is known on how these transmit to health workers (HWs). Addressing such a gap is timely as HWs are pivotal resources, particularly during pandemics or the ensuing recessions. Drawing from the empirical literature, we aimed to provide a framework for understanding the impact of recessions on HWs and their reactions. We use a systematic review and best-fit framework synthesis approach to identify the relevant qualitative, quantitative and mixed-methods evidence, and refine an a priori, theory-based conceptual framework. Eight relevant databases were searched, and four reviewers employed to independently review full texts, extract data and appraise the quality of the evidence retrieved. A total of 57 peer-reviewed publications were included, referring to six economic recessions. The 2010-15 Great Recession in Europe was the subject of most (52%) of the papers. Our consolidated framework suggests that recessions transmit to HWs through three channels: (1) an increase in the demand for services; (2) the impacts of austerity measures; and (3) changes in the health labour market. Some of the evidence appeared specific to the context of crises; demand for health services and employment increased during economic recessions in North America and Oceania, but stagnated or declined in Europe in connection with the austerity measures adopted. Burn-out, lay-offs, migration and multiple jobholding were the reactions observed in Europe, but job opportunities never dwindled for physicians during recessions in North America, with nurses re-entering labour markets during such crises. Loss of motivation, absenteeism and abuse of health systems were documented during recessions in low-income countries. Although the impacts of recessions may vary across economic events, health systems, labour markets and policy responses, our review and framework provide an evidence base for policies to mitigate the effects on HWs.

Therapeutic Borderlands: Austerity, Maternal HIV Treatment, and the Elusive End of AIDS in Mozambique

"End of AIDS" requires ambitious testing, treatment, and adherence benchmarks, like UNAIDS' "90-90-90 by 2020." Mozambique's efforts to improve essential maternal/infant antiretroviral treatment (ART) exposes how austerity-related health system short-falls impede public HIV/AIDS service-delivery and hinder effective maternal ART and adherence. In therapeutic borderlands-where household impoverishment intersects with health-system impoverishment-HIV+ women and over-worked care-providers circumnavigate scarcity and stigma. Worrisome patterns of precarious use emerge-perinatal ART under-utilization, delayed initiation, intermittent adherence, and low retention. Ending HIV/AIDS requires ending austerity and reinvesting in a public sector health workforce to ensure universal health coverage as household and community safety nets.

For the children? A mixed methods analysis of World Bank structural adjustment loans, health projects, and infant mortality in Latin America

Background

The World Bank wields immense financial and normative power in health in the developing world. During the 1980s and 1990s, in the face of intense criticism of its structural adjustment policies, the World Bank purportedly turned its attention to “pro-growth and pro-poor” policies and new lending instruments. One focus has been an investment in maternal and infant health. My analysis uses a mixed methods approach to examine the relationship between traditional structural adjustment and health loans and projects and infant mortality in Latin America and the Caribbean from 2000 to 2015.

Results

My answer to whether the World Bank’s projects in Latin America worked “for the children” is: somewhat. The results are heartening in that quantitatively, health projects are associated with lower infant mortality rates, net of controls, whereas traditional structural adjustment loans do not appear to be negatively associated with infant mortality, though examined across a short time horizon. Qualitative data suggest that infants, children, and mothers are considered in World Bank loans and projects in the context of an economic logic: focusing on productivity, economic growth, and human capital, rather than human rights.

Conclusion

Taken together, my results suggest that the World Bank appears to, at least partially, have amended its approach and its recent work in the region is associated with reductions in infant mortality. However, the World Bank’s economistic approach risks compartmentalizing healthcare and reducing people to their economic potential. As such, there remains work to do, in Latin America and beyond, if health interventions are to be effective at sustainably and holistically protecting vulnerable groups.

The Impact of Macroeconomic Policies on Healthcare Delivery in Kenya: An Analysis of the National Sexual Violence Prevention and Care Response

Sexual violence is one of the most common forms of violence against women in Kenya. This study documents the care of sexual violence survivors from the perspective of health care practitioners based on an analytic framework developed in studies of the political-economy of health to examine the effects of International Financial Institutions' conditionalities on the allocation of national fiscal resources. The study documented the working conditions of practitioners and myriad challenges that they experience in providing quality services to sexual violence survivors. The issues reflected in the results are grounded in social structural inequities driven by the global political economic policies that perpetuate poverty and dependency throughout Africa and the developing world. Macro-level variables associated with health care provision are assessed with a focus on global macroeconomic policies established by the International Monetary Fund and World Bank, their impact on Kenya's health economy and their ultimate impact on the capacity of the health system to meet the complex needs of survivors of sexual violence. In this paper, study results are analysed within the context of these macroeconomic policies and their legacy.

Structural competency and global health education

Structural competency is a new curricular framework for training health professionals to recognise and respond to disease and its unequal distribution as the outcome of social structures, such as economic and legal systems, healthcare and taxation policies, and international institutions. While extensive global health research has linked social structures to the disproportionate burden of disease in the Global South, formal attempts to incorporate the structural competency framework into US-based global health education have not been described in the literature. This paper fills this gap by articulating five sub-competencies for structurally competent global health instruction. Authors drew on their experiences developing global health and structural competency curricula-and consulted relevant structural competency, global health, social science, social theory, and social determinants of health literatures. The five sub-competencies include: (1) Describe the role of social structures in producing and maintaining health inequities globally, (2) Identify the ways that structural inequalities are naturalised within the field of global health, (3) Discuss the impact of structures on the practice of global health, (4) Recognise structural interventions for addressing global health inequities, and (5) Apply the concept of structural humility in the context of global health.

Global capitalism as a societal determinant of health: A conceptual framework

Recent scholarship has sought to distinguish between the deeper societal factors that shape the more proximate social determinants of health. One of these socio-structural institutions is global capitalism. While critical scholarship has advanced our understanding of the relationships between capitalist globalization and health, more work is needed to understand the transnational economic, political, and cultural practices that affect various global health issues. This paper argues that the theory of global capitalism provides an important, critical perspective for understanding different phenomena associated with global health. The theory's key concepts of transnational corporations, financialization, consumerism, transnational social classes, and transnational state comprise the conceptual framework. When applied to various global health topics, the theory advances our understanding of the health-related institutional structures of today's global economy, provides a holistic view that integrates various strands of health research, highlights various forms of health activism, and offers new questions for addressing persistent health injustice across the world.

Health services utilization and its determinants in the context of recession: evidence from Greece

BACKGROUND

In 2009, Greece entered a prolonged economic recession and adopted austerity reforms, which have profoundly affected many aspects of health sector, including health services use. The objective of this study was to investigate healthcare utilization in the Greek population in the context of austerity and its determinants.

METHODS

Two National Health Surveys of the population aged 15 and over, conducted in 2009 and 2014-before and after the adoption of austerity measures-, were used to analyse possible changes in healthcare utilization and its determinants applying chi-square tests, Mann-Whitney U-tests and generalized linear models.

RESULTS

Between 2009 and 2014, the share of those who had visited a specialist decreased, whereas that of those who had visited a general practitioner or had been hospitalized did not change significantly. The number of outpatient consultations decreased and the number of nights spent in hospital did not change significantly. The strongest predictors were self-rated health, presence of chronic diseases and experiencing pain.

CONCLUSIONS

Identifying the procyclical or counter-cyclical nature of healthcare utilization and the association between utilization and its determinants in different settings is an important priority in order to improve access and promote health equity.

Health Workers on the Frontline Struggle for Health as a Social Common

Through the lens of health workers’ concerns, the article interrogates the impact of the neoliberal turn of the 1980s on the loss of the ideal and pursuit of health as a social common. It highlights the Great Recession as a confirmation of the failure of the neoliberal project but notes that this the project continues with even greater frenzy. Capturing the dynamics which inhibit the World Health Organization, it calls for mass mobilization to reclaim health as a social common.

Diversity and Political Leaning: Considerations for Epidemiology

The positive effects of increased diversity and inclusion in scientific research and practice are well documented. In this issue, DeVilbiss et al. (Am J Epidemiol. 2020;189(10):998-1010) present findings from a survey used to collect information to characterize diversity among epidemiologists and perceptions of inclusion in the epidemiologic profession. They capture identity across a range of personal characteristics, including race, gender, socioeconomic background, sexual orientation, religion, and political leaning. In this commentary, we assert that the inclusion of political leaning as an axis of identity alongside the others undermines the larger project of promoting diversity and inclusion in the profession and is symptomatic of the movement for "ideological diversity" in higher education. We identify why political leaning is not an appropriate metric of diversity and detail why prioritizing ideological diversity counterintuitively can work against equity building initiatives. As an alternative to ideological diversity, we propose that epidemiologists take up an existing framework for research and practice that centers the voices and perspectives of historically marginalized populations in epidemiologic work.

Impact of the economic crisis on household health expenditure in Greece: an interrupted time series analysis

OBJECTIVES AND SETTING

The 2008 financial crisis had a particularly severe impact on Greece. To contain spending, the government capped public health expenditure and introduced increased cost-sharing. The Greek case is important for studying the impact of recessions on health systems. This study analysed changes in household health expenditure in Greece over the economic crisis and explored whether the impact differed across socioeconomic groups.

PARTICIPANTS

We used data from the Greek Household Budget Survey for the years 2004 and 2008-2017. The dataset comprised 51 654 households, with a total of 128 111 members.

DESIGN

We compared pre-crisis and post-crisis trends in Greek household out-of-pocket payments for healthcare from 2004 to 2017 using an interrupted time series analysis. This study explored spending in euros and as a share of total household purchases.

RESULTS

Our results indicated that the population level trend in household health spending was reversed after the crisis began (pre-crisis trend: €0.040 decrease per quarter (95% CI: -0.785 to -0.022), post-crisis trend: €0.315 increase per quarter (95% CI: -0.004 to 0.635)). We also found that spending on inpatient services and pharmaceuticals has been increasing since the start of the crisis, whereas outpatient services expenditure has been decreasing. Across all households, out-of-pocket payments incurred a greater financial burden after the crisis relative to pre-existing trends, but the poorest households incurred a disproportionately higher burden.

CONCLUSIONS

This was the first study to use an interrupted time series analysis to assess the impact of the economic crisis on household health expenditure in Greece. Our findings suggest that there was an erosion of financial protection for Greek households as a consequence of the economic crisis. This effect was particularly pronounced among poorer households, which is indicative of a regressive financing system.

Mapping health workforce development strategies across key global health agencies: an assessment of objectives and key interventions

The political and financial commitment to addressing the global shortage of health workers is stronger than ever before. Therefore, the global effort to strengthen human resources for health (HRH) must be co-ordinated and aligned to strategically utilize the current momentum and create sustainable impact. This paper assesses HRH strategies to (1) create greater understanding on the collective global action towards improving HRH, and (2) identify opportunities for greater co-ordination to improve sustainable health workforce development. We searched published and grey literature to identify the HRH strategies of select large-scale global health organizations. The most common approaches were increasing the supply of health workers, facilitating training and education and improving health worker management capacities. Overall, our analysis shows there is a need to (1) improve co-ordination among development partners, (2) ensure strong engagement and leadership of national governments and (3) generate scientific evidence on the best approaches for sustainable workforce development.

Government spending, recession, and suicide: evidence from Japan

Backgrounds

Austerity has been shown to have an adverse influence on people’s mental health and suicide rates. Most existing studies have focused on the governments’ reactions to a single event, for example, the Great Recession of 2008.

Methods

This study focused on significant changes in fiscal policy between 2001 and 2014 in Japan. The size of expenditures by national and local governments decreased dramatically between 2001 and 2006 under the neoliberal reform and then increased after the global economic crisis and the Great East Japan Earthquake. Using the data from 47 prefectures between 2001 and 2014, we tested whether more spending by the local governments was associated with a lower suicide rate in their jurisdiction. We also investigated whether this relationship was particularly salient during a more severe recession.

Results

Our analysis revealed that an increase of 1% in the per capita local government expenditures was associated with a decrease of 0.2% in the suicide rates among males and females aged between 40 and 64 and that this correlation was strengthened as the unemployment rate increased, particularly among males.

Conclusions

Government’s reaction to economic crises can either exacerbate or mitigate the negative impact of the economic recession on people’s mental health and suicide rates.

Job morale of physicians in low-income and middle-income countries: a systematic literature review of qualitative studies

OBJECTIVES

To systematically review the available literature on physicians' and dentists' experiences influencing job motivation, job satisfaction, burnout, well-being and symptoms of depression as indicators of job morale in low-income and middle-income countries.

DESIGN

The review was reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for studies evaluating outcomes of interest using qualitative methods. The framework method was used to analyse and integrate review findings.

DATA SOURCES

A primary search of electronic databases was performed by using a combination of search terms related to the following areas of interest: 'morale', 'physicians and dentists' and 'low-income and middle-income countries'. A secondary search of the grey literature was conducted in addition to checking the reference list of included studies and review papers.

RESULTS

Ten papers representing 10 different studies and involving 581 participants across seven low-income and middle-income countries met the inclusion criteria for the review. However, none of the studies focused on dentists' experiences was included. An analytical framework including four main categories was developed: work environment (physical and social), rewards (financial, non-financial and social respect), work content (workload, nature of work, job security/stability and safety), managerial context (staffing levels, protocols and guidelines consistency and political interference). The job morale of physicians working in low-income and middle-income countries was mainly influenced by negative experiences. Increasing salaries, offering opportunities for career and professional development, improving the physical and social working environment, implementing clear professional guidelines and protocols and tackling healthcare staff shortage may influence physicians' job morale positively.

CONCLUSIONS

There were a limited number of studies and a great degree of heterogeneity of evidence. Further research is recommended to assist in scrutinising context-specific issues and ways of addressing them to maximise their utility.

PROSPERO REGISTRATION NUMBER

CRD42017082579.

NGOs, austerity, and universal health coverage in Mozambique

In many African countries, hundreds of health-related NGOs are fed by a chaotic tangle of donor funding streams. The case of Mozambique illustrates how this NGO model impedes Universal Health Coverage. In the 1990s, NGOs multiplied across post-war Mozambique: the country’s structural adjustment program constrained public and foreign aid expenditures on the public health system, while donors favored private contractors and NGOs. In the 2000s, funding for HIV/AIDS and other vertical aid from many donors increased dramatically. In 2004, the United States introduced PEPFAR in Mozambique at nearly 500 million USD per year, roughly equivalent to the entire budget of the Ministry of Health. To be sure, PEPFAR funding has helped thousands access antiretroviral treatment, but over 90% of resources flow “off-budget” to NGO “implementing partners,” with little left for the public health system. After a decade of this major donor funding to NGOs, public sector health system coverage had barely changed. In 2014, the workforce/ population ratio was still among the five worst in the world at 71/10000; the health facility/per capita ratio worsened since 2009 to only 1 per 16,795. Achieving UHC will require rejection of austerity constraints on public sector health systems, and rechanneling of aid to public systems building rather than to NGOs.

Power asymmetries in global governance for health: a conceptual framework for analyzing the political-economic determinants of health inequities

Background

Recent scholarship has increasingly identified global power asymmetries as the root cause of health inequities. This article examines how such asymmetries manifest in global governance for health, and how this impacts health outcomes.

Results

We focus on the political-economic determinants of global health inequities, and how these determinants operate at different levels of social action (micro, meso, and macro) through distinct but interacting mechanisms. To clarify how these mechanisms operate, we develop an integrative framework for examining the links between global neoliberalism—the currently dominant policy paradigm premised on advancing the reach of markets and promoting ever-growing international economic integration—and global health inequities, and show how these mechanisms have macro–macro, macro–meso–macro, and macro–micro–macro manifestations.

Conclusions

Our approach enables the design of theoretically-nuanced empirical strategies to document the multiple ways in which the political economy entrenches or, alternatively, might ameliorate global health inequities.

Impact of economic recessions on healthcare workers and their crises' responses: study protocol for a systematic review of the qualitative and quantitative evidence for the development of an evidence-based conceptual framework

INTRODUCTION

During economic recessions, health professionals face reduced income and labour opportunities, hard conditions often exacerbated by governments' policy responses to crises. Growing evidence points to non-negligible effects on national health workforces and health systems-decrease in motivation, burnout, migration-arising from the combination of crisis-related factors. However, no theoretical conceptualisation currently exists framing the impacts recessions have on human resources for health (HRH), or on their reactions.

METHODS AND ANALYSIS

This paper lays out a protocol for a systematic review of the existing qualitative, quantitative and mixed-method evidence on the economic recessions and HRH; results from the review will be used to develop a conceptual framework linking existing theories on recessions, austerity measures, health systems and population health, with a view of informing future health policies. Eight relevant databases within the health, health systems, multidisciplinary and economic literature will be searched, complemented by secondary searches and experts' input. Eligible studies will present primary quantitative or qualitative evidence on HRH impacts, or original secondary analyses. We will cover the 1970-2019 period-the modern age of global economic recessions-and full texts in English, Spanish, Italian, French, Portuguese or Greek. Two reviewers will independently assess, perform data extraction and conduct quality appraisal of the texts identified. A 'best-fit' framework synthesis will be applied to summarise the findings, using an a priori, theoretically driven framework. That preliminary framework was built by the research team to inform the searches, and will be appraised by external experts.

ETHICS AND DISSEMINATION

In addition to peer-reviewed publications, the new framework will be presented in global health systems research conferences and inform regional policy dialogue workshops in Latin America on economic recessions and health systems.

PROSPERO REGISTRATION NUMBER

CRD42019134165.

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.

Globalization and health equity: The impact of structural adjustment programs on developing countries

Among the many drivers of health inequities, this article focuses on important, yet insufficiently understood, international-level determinants: economic globalization and the organizations that spread market-oriented policies to the developing world. One such organization is the International Monetary Fund (IMF), which provides financial assistance to countries in economic trouble in exchange for policy reforms. Through its 'structural adjustment programs,' countries around the world have liberalized and deregulated their economies. We examine how policy reforms prescribed in structural adjustment programs explain variation in health equity between nations-approximated by health system access and neonatal mortality. Our empirical analysis uses an original dataset of IMF-mandated policy reforms for a panel of up to 137 developing countries between 1980 and 2014. We employ regression analysis to evaluate the relationship between these reforms and health equity, taking into account the non-random selection and design of IMF programs. We find that structural adjustment reforms lower health system access and increase neonatal mortality. Additional analyses show that labor market reforms drive these deleterious effects. Overall, our evidence suggests that structural adjustment programs endanger the attainment of Sustainable Development Goals in developing countries.

Socioeconomic inequalities in health during the Great Recession: A scoping review of the research literature

Aims: The so-called ‘Great Recession’ in Europe triggered widespread concerns about population health, as reflected by an upsurge in empirical research on the health impacts of the economic crisis. A growing body of empirical studies has also been devoted to socioeconomic inequalities in health during the Great Recession. The aim of the current study is to summarise this health inequality literature by means of a scoping review. Methods: We have performed a scoping review of the research literature (English language) published in the years 2012–2017. Only empirical papers with (a) health status measured on the individual level, (b) information on socioeconomic position (i.e. employment status, educational level, income/wealth, and/or occupational class), and (c) data from European countries in both pre- and post-crisis years were considered relevant. In total, 49 empirical studies fulfilled these inclusion criteria. Results: The empirical findings in the 49 included studies predominantly show that socioeconomic inequalities in health either increased or remained stable from pre- to post-crisis years. Two-thirds (65%) of the studies found evidence of either increasing or partially increasing health inequalities. Thus, people in lower socioeconomic strata fared worse overall in terms of health during the Great Recession, compared to people with higher socioeconomic status. Conclusions: The Great Recession in Europe tends to be followed by increasing socioeconomic inequalities in health. Policymakers should take note of this finding. Widening socioeconomic inequalities in health is a major cause of concern, in particular if health deterioration among ‘vulnerable groups’ is caused by accelerating cumulative disadvantages.

Does trade liberalization reduce child mortality in low- and middle-income countries? A synthetic control analysis of 36 policy experiments, 1963-2005

Scholars have long argued that trade liberalization leads to lower rates of child mortality in developing countries. Yet current scholarship precludes definitive conclusions about the magnitude and direction of this relationship. Here I analyze the impact of trade liberalization on child mortality in 36 low- and middle-income countries, 1963–2005, using the synthetic control method. I test the hypothesis that trade liberalization leads to lower rates of child mortality, examine whether this association varies between countries and over time, and explore the potentially modifying role of democratic politics, historical context, and geographic location on the magnitude and direction of this relationship. My analysis shows that, on average, trade liberalization had no impact on child mortality in low- and middle-income countries between 1963 and 2005 (Average effect (AE): −0.15%; 95% CI: −2.04%–2.18%). Yet the scale, direction and statistical significance of this association varied markedly, ranging from a ∼20% reduction in child mortality in Uruguay to a ∼20% increase in the Philippines compared with synthetic controls. Trade liberalization was also followed by the largest declines in child mortality in democracies (AE 10-years post reform (AE₁₀): −3.28%), in Latin America (AE₁₀: −4.15%) and in the 1970s (AE₁₀: −6.85%). My findings show that trade liberalization can create an opportunity for reducing rates of child mortality, but its effects cannot be guaranteed. Inclusive and pro-growth contextual factors appear to influence whether trade liberalization actually yields beneficial consequences in developing societies.

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Impact of trade liberalization on child mortality is currently unclear.

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Analysis of this relationship using synthetic control method.

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There is no universal association between trade liberalization and child mortality.

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Impact of trade liberalization and child mortality varies substantially.

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Reductions in child mortality greatest in democracies, Latin America, and pre-1990.

Withstanding austerity: Equity in health services utilisation in the first stage of the economic recession in Southern Spain

Scant research is available on the impact of the current economic crisis and austerity policies on inequality in health services utilisation in Europe. This study aimed to describe the trends in horizontal inequity in the use of health services in Andalusia, Spain, during the early years of the Great Recession, and the contribution of demographic, economic and social factors. Consultation with a general practitioner (GP) and specialist, hospitalisation and emergency care were studied through the Andalusian Health Survey 2007 (pre-crisis) and 2011–2012 (crisis), using a composite income index as socioeconomic status (SES) indicator. Horizontal inequity indices (HII) were calculated to take differential healthcare needs into account, and a decomposition analysis of change in inequality between periods was performed. Results showed that before the crisis, the HII was positive (greater access for people with higher SES) for specialist visits but negative (greater access for people with lower SES) in the other three utilisation models. During the crisis no change was observed in inequalities in GP visits, but a pro-poor development was seen for the other types of utilisation, with hospital and emergency care showing significant inequality in favour of low income groups. Overall, the main contributors to pro-poor changes in utilisation were socio-economic variables and poor mental health, due to changes in their elasticities. Our findings show that inequalities in healthcare utilisation largely remained in favour of the less well-off, despite the cuts in welfare benefits and health services provision during the early years of the recession in Andalusia. Further research is needed to monitor the potential impact of such measures in subsequent years.

International financial institutions and human rights: implications for public health

Serving as lender of last resort to countries experiencing unsustainable levels of public debt, international financial institutions have attracted intense controversy over the past decades, exemplified most recently by the popular discontent expressed in Eurozone countries following several rounds of austerity measures. In exchange for access to financial assistance, borrowing countries must settle on a list of often painful policy reforms that are aimed at balancing the budget. This practice has afforded international financial institutions substantial policy influence on governments throughout the world and in a wide array of policy areas of direct bearing on human rights. This article reviews the consequences of policy reforms mandated by international financial institutions on the enjoyment of human rights, focusing on the International Monetary Fund and World Bank. It finds that these reforms undermine the enjoyment of health rights, labour rights, and civil and political rights, all of which have deleterious implications for public health. The evidence suggests that for human rights commitments to be met, a fundamental reorientation of international financial institutions' activities will be necessary.

The effects of neoliberal policies on access to healthcare for people with disabilities

Neoliberal reforms lead to deep changes in healthcare systems around the world, on account of their emphasis on free market rather than the right to health. People with disabilities can be particularly disadvantaged by such reforms, due to their increased healthcare needs and lower socioeconomic status. In this article, we analyse the impacts of neoliberal reforms on access to healthcare for disabled people. This article is based on a critical analytical review of the literature and on two case studies, Chile and Greece. Chile was among the first countries to introduce neoliberal reforms in the health sector, which led to health inequalities and stratification of healthcare services. Greece is one of the most recent examples of countries that have carried out extensive changes in healthcare, which have resulted in a deterioration of the quality of healthcare services. Through a review of the policies performed in these two countries, we propose that the pathways that affect access to healthcare for disabled people include: a) Policies directly or indirectly targeting healthcare, affecting the entire population, including disabled people; and b) Policies affecting socioeconomic determinants, directly or indirectly targeting disabled people, and indirectly impacting access to healthcare. The power differentials produced through neoliberal policies that focus on economic rather than human rights indicators, can lead to a category of disempowered people, whose health needs are subordinated to the markets. The effects of this range from catastrophic out-of-pocket payments to compromised access to healthcare. Neoliberal reforms can be seen as a form of structural violence, disproportionately affecting the most vulnerable parts of the population - such as people with disabilities - and curtailing access to basic rights, such as healthcare.

Potential barriers in healthcare access of the elderly population influenced by the economic crisis and the troika agreement: a qualitative case study in Lisbon, Portugal

BACKGROUND

The recent economic and financial crisis in Portugal urged the Portuguese Government in April 2011 to request financial assistance from the troika austerity bail out program to get aid for its government debt. The troika agreement included health reforms and austerity measures of the National Health Service (NHS) in Portugal to save non-essential health care costs. This research aimed to identify potential barriers among the elderly population (aged 65 and above) to healthcare access influenced by the economic crisis and the troika agreement focussing on the Memorandum of Understanding on Specific Economic Policy Conditionality (MoU) in Lisbon metropolitan area, Portugal.

METHODS

The qualitative study is including 13 semi-structured interviews of healthcare experts, municipality authority, health care providers, negotiator of the troika agreement, hospital managers, health economists and elderly. A content analysis was performed to evaluate the interviews applying Nvivo2011 software. The barriers identified were clustered towards the five areas of the 'Conceptual framework on health care access' by Levesque et al. (Int J Equity Health 12:18, 2013).

RESULTS

Healthcare access for the elderly was found inadequate in four areas of the framework: availability; appropriateness; approachability; and affordability. The fifth area on acceptability was not identified since the study neither followed a gender nor ethnic specific purpose. The main identified barriers were: current financial situation and pension cuts; insufficient provision and increased user fees in primary care; inadequate design and availability of hospital care service; lack of long-term care facilities; increased out-of-pocket-payment on pharmaceuticals; limitations in exemption allowances; cuts in non-emergent health transportation; increased waiting time for elective surgery; and poor unadapted housing conditions for elderly.

CONCLUSIONS

The health reforms and health budget cuts in the MoU implemented as part of the troika agreement have been associated with increasing health inequalities in access to healthcare services for the elderly population. The majority of responses disclosed an increasing deficiency across the entire National Health Service (NHS) to collaborate, integrate and communicate between the different healthcare sectors for providing adequate care to the elderly. An urgent necessity of restructuring the health care system to adapt towards the elderly population was implied.

Structural adjustment programmes adversely affect vulnerable populations: a systematic-narrative review of their effect on child and maternal health

Structural adjustment programmes of international financial institutions have typically set the fiscal parameters within which health policies operate in developing countries. Yet, we currently lack a systematic understanding of the ways in which these programmes impact upon child and maternal health. The present article systematically reviews observational and quasi-experimental articles published from 2000 onward in electronic databases (PubMed/Medline, Web of Science, Cochrane Library and Google Scholar) and grey literature from websites of key organisations (IMF, World Bank and African Development Bank). Studies were considered eligible if they empirically assessed the aggregate effect of structural adjustment programmes on child or maternal health in developing countries. Of 1961 items yielded through database searches, reference lists and organisations' websites, 13 met the inclusion criteria. Our review finds that structural adjustment programmes have a detrimental impact on child and maternal health. In particular, these programmes undermine access to quality and affordable healthcare and adversely impact upon social determinants of health, such as income and food availability. The evidence suggests that a fundamental rethinking is required by international financial institutions if developing countries are to achieve the Sustainable Development Goals on child and maternal health.

Impact of International Monetary Fund programs on child health

Parental education is located at the center of global efforts to improve child health. In a developing-country context, the International Monetary Fund (IMF) plays a crucial role in determining how governments allocate scarce resources to education and public health interventions. Under reforms mandated by IMF structural adjustment programs, it may become harder for parents to reap the benefits of their education due to wage contraction, welfare retrenchment, and generalized social insecurity. This study assesses how the protective effect of education changes under IMF programs, and thus how parents' ability to guard their children's health is affected by structural adjustment. We combine cross-sectional stratified data (countries, 67; children, 1,941,734) from the Demographic and Health Surveys and the Multiple Indicator Cluster Surveys. The sample represents ∼2.8 billion (about 50%) of the world's population in year 2000. Based on multilevel models, our findings reveal that programs reduce the protective effect of parental education on child health, especially in rural areas. For instance, in the absence of IMF programs, living in an household with educated parents reduces the odds of child malnourishment by 38% [odds ratio (OR), 0.62; 95% CI, 0.66-0.58]; in the presence of programs, this drops to 21% (OR, 0.79; 95% CI, 0.86-0.74). In other words, the presence of IMF conditionality decreases the protective effect of parents' education on child malnourishment by no less than 17%. We observe similar adverse effects in sanitation, shelter, and health care access (including immunization), but a beneficial effect in countering water deprivation.