Effects of the economic crisis on health: does a strong primary care system help?

1. Effects of the economic crisis on health: does a strong primary care system help? Peter P. Groenewegen NIVEL – Netherlands Institute for Health Services research

2. Economic crisis: the statistics% Unemployed per country across Europe Spain Greece

3. 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)

4. 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

5. Self-rated health over time Ireland Greece Portugal Hungary

6. Results • Effect of the crisis: Countrieswithhigherincrease in unemploymentandgovernmentdebt or decrease of GDP growth: higherself-rated health • Effect of strong PC system: Better access  lowerself-rated health Allother PC char’s: no effect • Interactionbetween crisis (rise of unempl) and PC system: Neg effect forstructure, access, continuity, coordination

7. Results • Effect of the crisis: Countrieswithhigherincrease in unemploymentandgovernmentdebt or decrease of GDP growth: higherself-rated health • Effect of strong PC system: Better access  lowerself-rated health Allother PC char’s: no effect • Interactionbetween crisis (rise of unempl) and PC system: Neg effect forstructure, access, continuity, coordination

8. Results • Effect of the crisis: Countrieswithhigherincrease in unemploymentandgovernmentdebt or decrease of GDP growth: higherself-rated health • Effect of strong PC system: Better access  lowerself-rated health Allother PC char’s: no effect • Combination of crisis (rise of unempl) and PC system: lowerself-rated healthforstructure, access, continuity, coordination

9. Results (continued) • Health inequality: unemployed, lowereducatedandlowerincomepeople have lowerself-ratedhealth • But equityeffectsof strong PC system: Combination of low educationwithstructure, coordinationandcomprehensivenes: higherself-rated health (negative effect for access) • Combination of low incomewithstructure, coordinationandcoordination: higherself-rated health

10. Results (continued) • Health inequality: unemployed, lowereducatedandlowerincomepeople have lowerself-ratedhealth • But equityeffectsof strong PC system: Combination of low educationwithstructure, coordinationandcomprehensivenes: higherself-rated health(negative effect for access) Combination of low incomewithstructure, coordinationandcomprehensiveness: higherself-rated health Handle with care! Analysis notyetdefinitive

11. Combination of PC comprehensivenessandeducationaffectsself-rated health

12. 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 questionsthananswers Cost action on Crisis, primary care andequity