COVID-19 and Unmet Healthcare Needs of Older People: Did Inequity Arise in Europe?

BACKGROUND: The disruption in healthcare provision due to the COVID-19 pandemic forced many non-urgent medical treatments and appointments to be postponed or denied, which is expected to have huge impact on non-acute health conditions, especially in vulnerable populations such as older people. Attention should be paid to equity issues related to unmet needs during the pandemic. METHODS: We calculated concentration indices to identify income-related inequalities and horizontal inequity in unmet needs due to postponed and denied healthcare in people over 50 during COVID-19, using data from the Survey on Health, Ageing and Retirement in Europe (SHARE). RESULTS: Very few countries show significant income-related inequalities in postponed, rescheduled or denied treatments and medical appointments, usually favouring the rich. Only Estonia, Italy and Romania show a significant horizontal inequity (HI) in postponed healthcare, which apparently favours the poor. Significant pro-rich inequity in denied healthcare is found in Italy, Poland and Greece. CONCLUSIONS: Although important income-related horizontal inequity in unmet needs of European older adults during the early waves of the COVID-19 pandemic is not evident for most countries, some of them have to carefully monitor barriers to healthcare access. Delays in diagnosis and treatments may ultimately translate into adverse health outcomes, reduced quality of life and, even, widen socio-economic health inequalities among older people.

Who Suffers From Pharmaceutical Poverty and What Are Their Needs? Evidence From a Spanish Region.

Background: Pharmaceutical poverty occurs when a patient cannot afford the cost of prescribed medication and/or medical products. Nonprofit organizations are covering the cost of medication to those patients in some contexts. The aim of the study was to describe the population of beneficiaries of the PB, a nongovernmental organization based on the primary healthcare system, which provides free-of-charge access to medicines and their utilization pattern of medicines and healthcare products. Methods: This was an observational study using PB beneficiary data collected between November 2017 and December 2018 in Catalonia. The Catalan Health Service provided information from the general population. A descriptive analysis of the beneficiaries' characteristics was conducted and compared to the general population. Results: The beneficiaries (N = 1,206) were mainly adults with a low level of education, unemployed, with functional disability, and with ≥1 child. Compared with the general population, the beneficiaries were older, had a lower level of education, showed a higher prevalence of functional disability, were less likely to be Spanish, and were more likely to be divorced and unemployed. The beneficiaries were polymedicated, and most were using medication related to the nervous (79%), musculoskeletal (68%), and cardiovascular system (56%) and alimentary tract and metabolism (68%). Almost 19% of beneficiaries used healthcare products. Female beneficiaries were older and more likely to be divorced or widowed, employed, and with children. Compared to men, women were more likely to use medicines for pain and mental disorders. The pediatric group used medications for severe, chronic conditions (heart diseases, autoimmune diseases, conduct disorders, and attention deficit hyperactivity disorder). Conclusion: Patients with severe, chronic, and disabling conditions are affected by pharmaceutical poverty. While the system of copayment remains unchanged, family physicians and pediatricians should explore economic barriers to treatment and direct their patients to resources that help to cover the cost of treatment.

¿Se puede permitir la gente pagar por la atención sanitaria? Nueva evidencia sobre la protección financiera en España

Este estudio forma parte de una serie de informes nacionales que han generado nueva evidencia sobre la protección financiera en los sistemas sanitarios europeos. La protección financiera es fundamental para la cobertura sanitaria universal y es una dimensión básica del desempeño de los sistemas sanitarios. A pesar de haber empeorado durante la crisis económica entre los años 2008 y 2014, la incidencia de los gastos catastróficos en salud en España es mucho menor de lo que cabría esperar dada la dependencia relativamente elevada de los pagos directos en España. Esto puede explicarse por los puntos fuertes de las políticas decobertura en el Sistema Nacional de Salud (SNS): cobertura sanitaria basada en la residencia, con la misma cobertura para los inmigrantes en situación no regularizada; una cartera de servicios completa en general; uso limitado de los copagos, y diferentes mecanismos para proteger a los usuarios de los copagos. Sin embargo, la cobertura presenta algunas deficiencias. Las causas principales del gasto catastrófico son la atención dental y los productos sanitarios en todos los quintiles de consumo, principalmente porque la atención dental y óptica están excluidas en gran medida de la cobertura del SNS. En el quintil más pobre, la causa del gasto catastrófico son los medicamentos de dispensación ambulatoria debidoa los copagos y a una protección inadecuada de los hogares de bajos ingresos con personas en edad de trabajar. Para reducir las necesidades insatisfechas y las dificultades financieras, las políticas deben centrarse en ampliar la cobertura del SNS para la atención dental y la atención óptica, así como seguir mejorando las modalidades de copago para reforzar la protección de los hogares más pobres en todos los grupos de edad.

Can people afford to pay for health care? New evidence on financial protection in Spain

This review is part of a series of country-based studies generating new evidence on financial protection in European health systems. Financial protection is central to universal health coverage and a core dimensionof health system performance. Despite worsening during the economic crisis from 2008 to 2014, the incidence of catastrophic health spending in Spain is much lower than would be expected given Spain’s relatively heavy reliance on out-of-pocket payments. This can be explained by strengths in the design of coverage policy in the National Health System (NHS): entitlement to the NHS based on residence, with the same degree of entitlement for undocumented migrants; a generally comprehensive benefits package; limited use of co-payments; and multiple mechanisms to protect people from co-payments. There are gaps in coverage, however. Catastrophic spending is driven by dental care and medical products in all consumption quintiles, mainly because dental and optical care for eyesight problems are largely excluded from NHS coverage. Catastrophic spending in the poorest quintile is also driven by outpatient medicines, reflecting co-payments and inadequate protection for low-incomehouseholds of working age. To reduce unmet need and financial hardship, policy should focus on expanding NHS coverage of dental care and optical care and further improving the design of co-payments to strengthenprotection for poorer households in all age groups.

Income-related inequalities in unmet dental care needs in Spain: traces left by the Great Recession.

BACKGROUND: Dental health is an important component of general health. Socioeconomic inequalities in unmet dental care needs have been identified in the literature, but some knowledge gaps persist. This paper tries to identify the determinants of income-related inequality in unmet need for dental care and the reasons for its recent evolution in Spain, and it inquires about the traces left by the Great Recession. METHODS: Data from the EU-SILC forming a decade (2007-2017) were used. Income-related inequalities for three years were measured by calculating corrected concentration indices (CCI), which were further decomposed in order to compute the contribution of different factors to inequality. An Oaxaca-type decomposition approach was also used to analyze the origin of changes over time. Men and women were analyzed separately. RESULTS: Pro-rich inequality in unmet dental care needs significantly increased over time (CCI 2007: - 0.0272 and - 0.0334 for males and females, respectively; CCI 2017: - 0.0704 and - 0.0776; p < 0.001). Inequality showed a clear "pro-cycle" pattern, growing during the Great Recession and starting to decrease just after the economic recovery began. Gender differences only were significant for 2009 (p = 0.004) and 2014 (p = 0.063). Income was the main determinant of inequality and of its variation along time -particularly for women-, followed by far by unemployment -particularly for men-; the contributions of both were mainly due to changes in elasticites. CONCLUSIONS: The Great Recession left its trace in form of a higher inequality in the access to dental care. Also, unmet need for dental care, as well as its inequality, became more sensitive to the ability to pay and to unemployment along recent years. To broaden public coverage of dental care for vulnerable groups, such as low-income/unemployed people with high oral health needs, would help to prevent further growth of inequality.

El impacto de la Gran Recesión en la salud mental en España. Informe SESPAS 2020 / Impact of Great Recession on mental health in Spain. SESPAS Report 2020

El objetivo de este artículo es identificar los efectos de la Gran Recesión sobre la salud mental de las personas residentes en España. Tras exponer un marco conceptual sobre los mecanismos por los que las crisis económicas afectan a la salud mental, se describen los principales resultados de 45 trabajos identificados en nuestra búsqueda. Los estudios apuntan a un empeoramiento de la salud mental en España en los años de crisis económica, en especial en los varones. Las condiciones laborales (desempleo, bajos salarios, inestabilidad, precariedad) emergen como uno de los cauces principales a través de los que se pone en riesgo o deteriora la salud mental. Dicho deterioro se produce con intensidad en colectivos particularmente vulnerables, como población inmigrante y familias con cargas económicas. En el caso de los suicidios, no se observan resultados concluyentes. En materia de utilización de servicios sanitarios parece identificarse un aumento en el consumo de ciertos fármacos, si bien las conclusiones de todos los trabajos no son coincidentes. En el caso de las desigualdades sociales en salud mental, estas no parecen haber remitido. Se concluye que es necesario mejorar nuestros sistemas de información para comprender mejor los efectos sobre la salud de las crisis económicas. En materia de políticas públicas, junto con el refuerzo de los servicios sanitarios dirigidos a atender problemas de salud mental, se debería impulsar una red de garantía de rentas para las personas en situación de vulnerabilidad y el desarrollo de políticas dirigidas al medio laboral

The objective of this article is to identify the effects of the Great Recession on the mental health of people residing in Spain. After presenting a conceptual framework on the mechanisms through which economic crises affect mental health, we describe the main results of 45 papers identified in our search. Studies indicate a worsening of mental health in Spain in the years of economic crisis, especially in men. Working conditions (unemployment, low wages, instability, precariousness) emerge as one of the main channels through which mental health is put at risk or deteriorates. This deterioration occurs with intensity in particularly vulnerable groups, such as immigrant population and families with economic burdens. In the case of suicides, the results were inconclusive. Regarding the use of health care services, an increase in the consumption of certain drugs seems to be identified, although the conclusions of all the studies are not coincidental. Social inequalities in mental health do not seem to have remitted. We conclude that Spain needs to improve information systems to a better understanding of the health effects of economic crises. In terms of public policies, together with the reinforcement of health services aimed at addressing mental health problems, an income guarantee network for people in vulnerable situations should be promoted, as well as the development of policies aimed at the labour market

Economic burden of Huntington's disease in Peru.

BACKGROUND: Huntington's disease (HD) is a devastating and fatal neurodegenerative disorder that leads to progressive disability, and over time to total dependence. The economic impact of HD on patients living in developing countries like Peru is still unknown. This study aims to estimate the economic burden by estimating direct and indirect costs of Huntington's disease in Peru, as well as the proportion of direct costs borne by patients and their families. METHODS: Disease-cost cross-sectional study where 97 participants and their primary caregivers were interviewed using a common questionnaire. Prevalence and human capital approaches were used to estimate direct and indirect costs, respectively. RESULTS: The average annual cost of HD reached USD 8120 per patient in 2015. Direct non-healthcare costs represented 78.3% of total cost, indirect costs 14.4% and direct healthcare costs the remaining 7.3%. The mean cost of HD increased with the degree of patient dependency: from USD 6572 for Barthel 4 & 5 (slight dependency and total independency, respectively) to USD 23,251 for Barthel 1 (total dependency). Direct costs were primarily financed by patients and their families. CONCLUSIONS: The estimated annual cost of HD for Peruvian society reached USD 1.2 million in 2015. The cost impact of HD on patients and their families is very high, becoming catastrophic for most dependent patients, and thus making it essential to prioritize full coverage by the State.

Changes in income-related inequalities in cervical cancer screening during the Spanish economic crisis: a decomposition analysis.

BACKGROUND: Cervical cancer is one of the most prevalent cancers, but it may be prevented by early detection. Social inequalities in the use of cytology testing have been identified in the literature. However, the degree of income-related inequality has not been quantified and determinants of inequality changes during the economic crisis remain unknown. METHODS: Using the Spanish National Health Surveys (2006-07 / 2011-12), we analyzed how income-related inequalities in the use of cervical cancer screening for women aged 25-64 changed across the economic crisis. We used corrected concentration indices (CCI) which were further decomposed in order to compute the contribution of the explanatory variables. An Oaxaca-type approach was employed to investigate the origin of changes over time. RESULTS: Our final sample consisted of 10,743 observations in 2006-07 and 6587 in 2011-12. Despite the higher prevalence of screening over time (from 73.9 to 77.9%), pro-rich inequality significantly increased (from CCI = 0.1726 to CCI = 0.1880, p < 0.001). Income was the main determinant of inequality in cervical screening, although its contribution decreased over time, as well as the contribution of the type of health insurance, mainly due to changes in elasticity. Other factors, such as nationality or the educational level, seem to have played an important role in the increase of pro-rich inequality of cytology testing. CONCLUSIONS: Reducing cervical screening inequalities would require actions focused on most vulnerable groups such as migrants, low income and low educated population. The implementation of population-based screening programs would also help to cope with income-related inequalities in cytology testing.

Estimating direct effects of parental occupation on Spaniards' health by birth cohort.

BACKGROUND: Social health inequalities in adult population are partly due to socioeconomic circumstances in childhood. A better understanding of how those circumstances affect health during adulthood may improve the opportunities for reducing health disparities. The objective of this study is to investigate the effect of parental socioeconomic status, which is proxied by occupation, on adult Spaniards' health by birth cohort. The analysis will allow checking not only the direct impact of parental occupation on their offspring's health, but also whether inherited inequality has been reduced over time. METHODS: We use data from the Bank of Spain's Survey of Household Finances on Spanish households from 2002 to 2008. Sequential models were used to estimate the influence of the father's and mother's occupation on their offspring's health, trying to disentangle direct from indirect effects. With a sample of 26,832 persons we consider effects for four different cohorts by birth periods ranging from 1916 to 1981. RESULTS: The results show that parental occupation has a significant direct impact on individuals' health (p < 0.01). The effect of father's occupation exceeds that of mother's. For those born before 1936, the probability of reporting a good health status ranges from 0.31 (95% confidence interval (CI) 0.14-0.48), when fathers were classified as unskilled elementary workers, to 0.98 (95% CI 0.98-0.99) when they were managers or mid-level professionals. For those born during the period 1959-1975, those probabilities are 0.49 (95% CI 0.39-0.59) and 0.97 (95% CI 0.96-0.98), respectively. Therefore, health inequalities linked to parental socioeconomic status have been noticeably reduced, although discrimination against unskilled workers persists over time. CONCLUSIONS: Great progress has been made in the health area during the twentieth century, so that the impact of parental socioeconomic status on individuals' health has been significantly tempered for those at the bottom of the social scale. However, more efforts focused on the improvement of living conditions for most socioeconomically disadvantaged are needed in order to further reduce social inequalities in health.

Decomposing socio-economic inequalities in leisure-time physical inactivity: the case of Spanish children.

BACKGROUND: Physical inactivity is associated with an increased risk of all-cause mortality and entails a substantial economic burden for health systems. Also, the analysis of inequality in lifestyles for young populations may contribute to reduce health inequalities during adulthood. This paper examines the income-related inequality regarding leisure-time physical inactivity in Spanish children. METHODS: In this cross-sectional study based on the Spanish National Health Survey for 2011-12, concentration indices are estimated to measure socioeconomic inequalities in leisure-time physical inactivity. A decomposition analysis is performed to determine the factors that explain income-related inequalities. RESULTS: There is a significant socioeconomic gradient favouring the better-off associated with leisure-time physical inactivity amongst Spanish children, which is more pronounced in the case of girls. Income shows the highest contribution to total inequality, followed by education of the head of the household. The contribution of several factors (education, place of residence, age) significantly differs by gender. CONCLUSIONS: There is an important inequity in the distribution of leisure-time physical inactivity. Public policies aimed at promoting physical activity for children should prioritize the action into the most disadvantaged subgroups of the population. As the influence of determinants of health styles significantly differ by gender, this study points out the need of addressing the research on income-related inequalities in health habits from a gender perspective.

Disentangling effects of socioeconomic status on obesity: A cross-sectional study of the Spanish adult population.

This paper complements previous estimations regarding socioeconomic inequalities in obesity for Spanish adults, and provides new evidence about the mechanisms through which socioeconomic status (SES) affects obesity. Microdata from the Spanish National Health Survey (SNHS) 2011-2012 are analysed. Corrected concentration indices (CCI) are calculated to measure inequality. Path analysis is employed to disentangle direct and indirect effects of SES on obesity, where dietary patterns, physical activity and sleep habits act as mediator variables. Multivariate logistic models are used to select those exogenous variables to be included in the path diagram. Men and women are analysed separately. Our results show significant pro-rich inequality in the distribution of obesity (the poorer the more obese), particularly for women (CCI=-0.070 for men, CCI=-0.079 for women). The indirect effects of SES on obesity (those transmitted via mediator variables) are quite modest (3.3% for males, 2.4% for females) due to three reasons. Firstly, dietary habits do not show a significant mediating effect. Secondly, the mediating effect of physical activity in leisure time, although significant (14% for males, 11.1% for females), is offset by that related to main activity. Finally, sleep habits contribution to total effect of SES on obesity is statistically significant but small (roughly 1%). Our results indicate that promoting physical activity in leisure time for those with a low SES, particularly for men, would contribute to prevent obesity and to reduce health inequalities. Promotion of adequate sleep habits for women with a low SES might have a similar effect. However, interventions aimed to reduce sedentarism related to main activity, although useful to prevent obesity, would amplify the obesity socioeconomic gradient. Since effects of SES are different for men and women, socioeconomic health inequalities should be addressed also from a gender perspective.

The influence of the economic crisis on the association between unemployment and health: an empirical analysis for Spain.

OBJECTIVES: To estimate the impact of (particularly long-term) unemployment on the overall and mental health of the Spanish working-age population and to check whether the effects of unemployment on health have increased or been tempered as a consequence of the economic crisis. METHODS: We apply a matching technique to cross-sectional microdata from the Spanish Health Survey for the years 2006 and 2011-2012 to estimate the average treatment effect of unemployment on self-assessed health (SAH) in the last year, mental problems in the last year and on the mental health risk in the short term. We also use a differences-in-differences estimation method between the two periods to check if the impact of unemployment on health depends on the economic context. RESULTS: Unemployment has a significant negative impact on both SAH and mental health. This impact is particularly high for the long-term unemployed. With respect to the impact on mental health, negative effects significantly worsen with the economic crisis. For the full model, the changes in effects of long-term unemployment on mental problems and mental health risk are, respectively, 0.35 (CI 0.19-0.50) and 0.20 (CI 0.07-0.34). CONCLUSIONS: Anxiety and stress about the future associated with unemployment could have a large impact on individuals' health. It may be necessary to prevent health deterioration in vulnerable groups such as the unemployed, and also to monitor specific health risks that arise in recessions, such as psychological problems.

Public healthcare expenditure in Spain: measuring the impact of driving factors.

OBJECTIVES: To assess the impact of demography, health status, death related costs and some macroeconomic variables on the evolution of health expenditure. METHODS: We follow the methodology used by the Ageing Working Group (AWG) of the European Union to simulate expenditure projections on the basis of healthcare expenditure profiles for age-sex population groups. We estimate the profiles using data from Hospital Discharges Statistics and the Spanish National Health Survey. RESULTS: The differences between the compression of morbidity scenario and the expansion of morbidity scenario range from 1.35 to 1.57 points of GDP in 2060. The overestimation of healthcare expenditure when death related costs are ignored ranges from 0.04 to 0.11 percentage points, depending on the health status hypothesis. Moreover, the effect of death related cost diminishes as health status improves. CONCLUSIONS: Our results support the fact that intensity of healthcare use, instead of ageing, is the main driver of health expenditure. Thus, the concern of keeping expenditure under control should be focused on factors such as the population's health status, economic growth and development, new technologies and medical progress, and the organization and management of the healthcare system.

Social inequalities in health: measuring the contribution of housing deprivation and social interactions for Spain.

INTRODUCTION: Social factors have been proved to be main determinants of individuals' health. Recent studies have also analyzed the contribution of some of those factors, such as education and job status, to socioeconomic inequalities in health. The aim of this paper is to provide new evidence about the factors driving socioeconomic inequalities in health for the Spanish population by including housing deprivation and social interactions as health determinants. METHODS: Cross-sectional study based on the Spanish sample of European Statistics on Income and Living Conditions (EU-SILC) for 2006. The concentration index measuring income-related inequality in health is decomposed into the contribution of each determinant. Several models are estimated to test the influence of different regressors for three proxies of ill-health. RESULTS: Health inequality favouring the better-off is observed in the distribution of self-assessed health, presence of chronic diseases and presence of limiting conditions. Inequality is mainly explained, besides age, by social factors such as labour status and financial deprivation. Housing deprivation contributes to pro-rich inequality in a percentage ranging from 7.17% to 13.85%, and social interactions from 6.16% to 10.19%. The contribution of some groups of determinants significantly differs depending on the ill-health variable used. CONCLUSIONS: Health inequalities can be mostly reduced or shaped by policy, as they are mainly explained by social determinants such as labour status, education and other socioeconomic conditions. The major role played on health inequality by variables taking part in social exclusion points to the need to focus on the most vulnerable groups.

Equity and equality in the use of GP services for elderly people: the Spanish case.

OBJECTIVES: To present new evidence both on the horizontal inequity in the delivery of primary health care and on the factors driving inequalities in the use of GP services for Spanish population aged 50 years and over. METHODS: Cross-sectional study based on the Spanish sample of the Survey of Health, Aging and Retirement in Europe (SHARE) for 2006-07. We use the index proposed by Wagstaff and van Doorslaer (HI(WV)) to compute health care inequity. The concentration index measuring income related inequality in health care use is decomposed into the contribution of each determinant. RESULTS: Our results show the presence of pro-poor inequality in both the access and the frequency of use for GP services, which is mainly explained by unequal distribution of need factors. The contribution of non-need factors to income related inequality is quite higher for the conditional number of GP visits (48.13%) than for the probability of positive use (17.55%). We have also found significant pro-poor inequity in the probability of access to a GP and in the conditional number of visits for elderly people. CONCLUSIONS: The relevance of social determinants of health is confirmed, and hence the need for wide-scoped public policies to reduce health inequalities. At equal levels of need, rich and poor elderly people are not treated equally. As much as appropriateness of care provided is unknown, we cannot conclude that inequity in GP services really favours the lower income individuals in terms of health gains.

Síntesis final y recomendaciones para las políticas. Informe SESPAS 2008 / Final summary and policy recommendations

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