Effects of the economic crisis on health: does a strong primary

care system help?

Peter P. GroenewegenNIVEL – Netherlands Institute for Health

Services research

Economic crisis: the statistics% Unemployed per country across Europe

Spain

Greece

Expectations• More severely affected by economic crisis self-

rated health worse• Stronger primary care self-rated health less

affected by crisis.• This is strongest for the dimension access to

primary care.• And best visible for vulnerable people

(unemployed, low education, low income)

Data and methods• Strength of primary care derived from the 31 country study

PHAMEU (2009/10): – 5 dimensions: combined structure, access, coordination,

comprehensiveness, continuity.

• Economic situation of countries derived from Eurostat and UNECE statistics 2000-2010: – GDP, growth of GDP, unemployment and state debt

• Self-rated health and individual background characteristics derived from the European Social Survey:– Variables: self-rated health, age (>=25), sex, urban/rural, income,

education, employment status, ethnic minority – Collected in 2002, 2004, 2006, 2008 and 2010 among 26 European

countries (not all countries available in all waves).– Total sample 177.680 people

Self-rated health over time

Greece

Ireland

Hungary Portugal

Results• Effect of the crisis:

Countries with higher increase in unemployment and government debt or decrease of GDP growth: higher self-rated health

• Effect of strong PC system: Better access lower self-rated healthAll other PC char’s: no effect

• Interaction between crisis (rise of unempl) and PC system: Neg effect for structure, access, continuity, coordination

Results

• Effect of the crisis: Countries with higher increase in unemployment and government debt or decrease of GDP growth: higher self-rated health

• Effect of strong PC system: Better access lower self-rated healthAll other PC char’s: no effect

• Interaction between crisis (rise of unempl) and PC system: Neg effect for structure, access, continuity, coordination

Results• Effect of the crisis:

Countries with higher increase in unemployment and government debt or decrease of GDP growth: higher self-rated health

• Effect of strong PC system: Better access lower self-rated healthAll other PC char’s: no effect

• Combination of crisis (rise of unempl) and PC system: lower self-rated health for structure, access, continuity, coordination

Results (continued)

• Health inequality: unemployed, lower educated and lower income people have lower self-rated health

• But equity effects of strong PC system: Combination of low education with structure, coordination and comprehensivenes: higher self-rated health (negative effect for access)

• Combination of low income with structure, coordination and coordination: higher self-rated health

Results (continued)

• Health inequality: unemployed, lower educated and lower income people have lower self-rated health

• But equity effects of strong PC system:

Combination of low education with structure, coordination and comprehensivenes: higher self-rated health (negative effect for access)

Combination of low income with structure, coordination and comprehensiveness: higher self-rated health

Handle with care!Analysis not yet definitive

Combination of PC comprehensiveness and education affects self-rated health

Why are findings so contrary to our expectations?

• Selective samples (percentage unemployed far lower than national data)

• Small and heterogeneous numbers of countries, not all years

• Delays in health effects?• Strongest effects in the literature: mental health• Localized effects of crisis – local strong PC?

More new questions than answers

Cost action on Crisis, primary care and equity