The dynamics of international health system reforms: Evidence of a new wave in response to the 2008 economic crisis and the COVID-19 pandemic?

Global economic and health shocks, such as the 2008 global financial crisis and the COVID-19 pandemic typically impact healthcare financing and delivery. Cutler found that profound societal changes in the 20th century induced three waves of healthcare reform across seven major OECD countries. Our study investigates whether major crises in the 21st century induced similar reform waves. Through thematic analysis, we systematically compared health system changes in response to these shocks, using data from the Observatory on Health Systems and Policies and the OECD. Our analysis reveals similar overarching reform trends across countries in response to the 2008 economic crisis: a tendency toward re-centralization of health system governance to control and leverage the efficient rationalization of public health resources. This, to some extent, countered the effects of the market-based reforms of the previous wave. The reforms induced by the 2008 crisis were mediated by its repercussions on the countries' economies. In contrast, reforms in response to the pandemic aimed primarily to address the direct impact of the shock on the health system. Despite its negative economic impact, the pandemic resulted in a substantial but temporary increase in public health spending. A better understanding reform dynamics and their impact on overarching conflicting health system objectives may prevent unintended consequences and enhance health systems' resilience in response to future shocks.

Assessment of dietary-lifestyle patterns and adherence to the USDA recommendations in Lebanese pregnant women amid the economic crisis: Findings from a national representative cross-sectional study.

As Lebanon's economic crisis become uncontrollable, Lebanese pregnant women face malnutrition, with many having to skip meals and switch to resort to cheap and unhealthy alternatives altogether. The objectives of the study were to assess the dietary and lifestyle patterns of Lebanese pregnant women and to evaluate their diets compliance with the United States Department of Agriculture (USDA) pregnancy recommendations, before and during the Lebanese escalating economic crisis. A cross-sectional study was conducted between April 2021 and January 2022. A validated self-administrated questionnaire was administered during the first, second and third trimesters of pregnancy among 363 women in all Lebanese governorates. Most of the pregnant women were free of diseases. While the majority did not smoke, 14.1% smoked hookah / shisha during pregnancy. The adherence to the USDA recommendations in our sample did not significantly vary prior to and throughout the socioeconomic crisis, and it was generally low. Only the mean consumption of vegetables increased during the socioeconomic crisis (p<0.05). Regarding physical activity, while the proportion of active women slightly decreased during the socioeconomic crisis, around 55% were still active. In conclusion, higher attention should be given to the dietary habits and health of this critical population, through effective interventions that increase awareness and achieve measurable improvements.

Impact of the economic crisis, COVID-19 and the Beirut explosion on ophthalmology training in Lebanon: an observational cohort survey-based study.

OBJECTIVES: The objective of the study is to investigate the effects of the COVID-19 pandemic, the economic crisis and the Beirut explosion on the training and work of ophthalmology residents and faculty in Lebanon. DESIGN: This is an observational cohort survey-based research conducted between January and December 2022. SETTING: The study targeted all ophthalmology residents and core faculty in Lebanon. PARTICIPANTS: A total of 52 participants, including 27 residents and 25 core faculty members, completed the survey. PRIMARY OUTCOME MEASURE: Primary outcomes comprised the subjectively reported effect of the three major external stressors on the training and well-being of ophthalmology trainees and educators in Lebanon. RESULTS: The study found that the majority of ophthalmology residents and core faculty members were significantly affected by the COVID-19 pandemic, Beirut explosion and the economic crisis in Lebanon. Significant percentage reported financial burden, decrease in outpatient and surgical load and educational activities. Furthermore, most participants reported higher levels of stress, anxiety and depression during the time of crises. CONCLUSIONS: This study emphasises the need to support healthcare professionals during times of crisis, as they are on the frontlines and can experience high levels of stress, anxiety and depression. By providing support and resources to healthcare professionals, they can better cope with the challenges they face and continue to provide essential care to their patients.

Unveiling the unseen toll: exploring the impact of the Lebanese economic crisis on the health-seeking behaviors in a sample of patients with diabetes and hypertension.

BACKGROUND: Against the backdrop of Lebanon's escalating multifaceted crisis which resulted in medication shortages for chronic diseases and unaffordable healthcare services, the current study endeavors to shed light on a critical yet overlooked facet of the Lebanese economic crisis- its profound impact on the health-seeking behaviors of patients with hypertension and diabetes mellitus. METHODS: An exploratory cross-sectional study based on an online questionnaire was conducted on 156 adult Lebanese citizens diagnosed medically with either hypertension or diabetes. We gathered sociodemographic characteristics and healthcare-related challenges faced during the economic crisis. We also assessed stress levels using the Depression Anxiety Stress Scale (DASS-21). Descriptive and bivariate analyses were done using SPSS version 26. RESULTS: The mean age of the population was 49.8 ± 17.7 years old, 51.6% were females and 48.4% were males, 29.7% had diabetes, 51.3% had hypertension and 19.0% had both diseases. Among all, 84.2% reported dissatisfaction with the current healthcare system, 31.6% reported changing their physician mainly because of unaffordable consultation fees (66%) or immigration of the physician (32%). Of those with hypertension and/or diabetes, less than 20% reported finding all their prescribed medications and 47% either modified or discontinued their treatment without seeking medical advice. In case of drug shortage, patients relied on stocked reserves (26%), alternative/generic medications (10%) and external sources for medication procurement such as relatives living abroad (41.7%), outsourcing suppliers (19.9%), dispensaries (19.6%) and NGOs (20.3%). All participants reported a high stress level (5.03/7) with a mean total DASS-21 score of 38.7 ± 35.8 that were attributed to August 4th Beirut port explosion (81.0%), global pandemic (81%), unstable political conditions (90.5%), economic crisis (96.8%), medication shortage (91.8%) and inability to access healthcare (74.1%). Higher sub-scores for anxiety, depression and total stress were insignificantly noted in participants with both hypertension and diabetes (p > 0.05). CONCLUSION: Our findings explore how the economic crisis has taken its toll on almost all aspects of healthcare in a sample of patients with diabetes and hypertension in Lebanon. The drug shortage as well as disruptions in affordable healthcare access imposed several barriers to adequate adherence to treatment regimens and acted as important mental health stressors.

Economic activity and suicides: Causal evidence from macroeconomic shocks in England and Wales.

The relationship between economic activity and suicides has been the subject of much scrutiny, but the focus in the extant literature has been almost exclusively on estimating associations rather than causal effects. In this paper, using data from England and Wales between January 1, 1997 and December 31, 2017, we propose a plausible set of assumptions to estimate the causal impacts of well-known macroeconomic variables on the daily suicide rate. Our identification strategy relies on scheduled macroeconomic announcements and professional economic forecasts. An important advantage of using these variables to model suicide rates is that they can efficiently capture the elements of 'surprise or shock' via the observed difference between how the economy actually performed and how it was expected to perform. Provided that professional forecasts are unbiased and efficient, the estimated 'surprises or shocks' are 'as good as random', and therefore are exogenous. We employ time series regressions and present robust evidence that these exogenous macroeconomic shocks affect the suicide rate. Overall, our results are consistent with economic theory that shocks that reduce estimated permanent income, and therefore expected lifetime utility, can propel suicide rates. Specifically, at the population level, negative shocks to consumer confidence and house prices accelerate the suicide rate. However, there is evidence of behavioural heterogeneity between sexes, states of the economy, and levels of public trust in government. Negative shocks to the retail price index (RPI) raise the suicide rate for males. Negative shocks to the growth rate in gross domestic product (GDP) raise the population suicide rate when the economy is doing poorly. When public trust in government is low, increases in the unemployment rate increase the suicide rate for females.

The policy and politics of healthcare corporatisation: The case of the English NHS.

RATIONALE: Few accounts of healthcare corporatisation examine the effects of the 2008 financial crisis. New Politics of the Welfare State (NPWS) theories recognise the relevance of crises but give more attention to programmatic than systemic (structural) retrenchment, and little to healthcare corporatisation. OBJECTIVE: To examine what changes the 2008 financial crisis produced in the pattern of healthcare corporatisation, and the implications for NPWS theories. METHODS: Using administrative data from the English NHS during 1995-2019 we formulated a multi-dimensional index of corporatisation, tested its validity, and used it to analyse longitudinally how the financial crisis affected the balance between the responsibilization of management and re-commodification (introduction of market-like practices) in provider corporatisation. RESULTS: The financial crisis influenced NHS corporatisation through the fiscal austerity with which governments responded. The re-commodification of NHS providers stalled but not the responsibilization of NHS managers. CONCLUSIONS: The corporatisation of NHS providers faltered after the financial crisis. These findings corroborate parts of NPWS theory but also reveal scope for further elaborating its accounts of systemic retrenchment in health systems.

Drug persistence in patients with rheumatic and musculoskeletal diseases during a major economic crisis: results from a nationwide cross-sectional online survey.

To evaluate the drug persistence in patients with rheumatic and musculoskeletal diseases (RMDs) during the current economic crisis in Lebanon and to estimate predictors of persistence. A nationwide multicentric cross-sectional study using an online questionnaire was conducted in Lebanon with patients with chronic inflammatory rheumatic diseases (CIRDs) and non-inflammatory RMDs controls between July and October 2022. Disease-modifying antirheumatic drugs (DMARDs) were categorized as conventional synthetic (cs), biological (b), subcutaneous (SC) or intravenous (IV), and targeted synthetic (ts). Persistence was defined as "number of tablets or injections taken during the past month versus prescribed". The percentage of patients who discontinued or changed treatment due to cost or non-availability was reported. Factors associated with persistence were identified using multivariable linear regression. The study included 317 patients with RMDs (286 CIRDs); mean age 49.5 years, 68% females, 58% reporting currently low economic level. Persistence at one month was low for tsDMARDs (36%) and bDMARDs (SC55%, IV63%), and acceptable for csDMARDs (88%). A persistence ≥80% was found in 23.3% of patients on tsDMARDs, 42.9% on SC bDMARDs, 45.0% on IV bDMARDs, and 74.7% on csDMARDs. During the past 6 months, 55.8% of CIRD patients discontinued or changed treatment due to non-availability (45.3%) or cost (21.2%). Persistence was positively associated with finding alternative sources such as buying abroad (36%), depending on friends or families abroad (20%), charities (10%), and negatively associated with unemployment and low financial status. Persistence was significantly compromised for essential antirheumatic drugs and was mostly driven by treatment unavailability and cost.

Young graduates and economic recession: Lessons from the pandemic to prevent the (re)incidence of mental health symptoms.

Economic conditions affect the youth labour market and can leave deep scars. This exploratory study examines the emotional responses and mental health symptoms of young graduates during their transition into the labour market in the pandemic context. It draws on 42 news articles with statements from 86 graduates from a set of European and non-European countries. The graduates had jobs or internships cancelled, numerous applications unanswered or were dismissed from jobs they had recently started. Young people adopt a variety of coping strategies, which are often invisible and cause deep suffering due to anxiety, disappointment, fear, and depression. Their apprehension and uncertainty leave them in a state of limbo. The specific impacts of the pandemic on young people's lives serve as a warning of the need to protect future generations of graduates. More support is required worldwide to manage the mental health issues that affect young graduates, especially during economic recessions.

Perinatal health in Spain during and after the Great Recession: Educational selection into fertility as a protective factor in high unemployment contexts.

Higher maternal resources have long been associated with superior birth outcomes. This study analyzes the potentially protective role of maternal educational selection into fertility in adverse macroeconomic contexts. We focus on the case of Spain, a country reaching record-high unemployment levels during the Great Recession starting in 2008. First, we examine whether selection into fertility of more educated mothers took place as province-level unemployment rates rose. Secondly, we assess whether maternal education mitigated the impact of higher unemployment levels on different birth outcomes. The analysis combines register data on the universe of live births with aggregate data on province-level unemployment. We cover the period 2007-2019 to ensure sufficient variability of unemployment rates and perform linear regression and linear probability models with fixed effects to hold constant unobserved heterogeneity across provinces. Findings indicate selection into fertility of mothers with university-level education in times of high unemployment. In addition, while unemployment rates did show an adverse impact on certain birth outcomes -birthweight, the occurrence of low and very low birthweight, and the risk of stillbirth - maternal education mitigated the observed relations. It was itself, moreover, consistently and independently associated with better perinatal health. We thus conclude that fertility selectivity by maternal education cushioned the impact of the adverse economic context derived from the Great Recession through two separate pathways.

When the economy falters, hearts suffer: Economic recessions as a social determinant of health in cardiovascular emergencies.

INTRODUCTION: While the relationships between cardiovascular disease (CVD), stress, and financial strain are well studied, the association between recessionary periods and macroeconomic conditions on incidence of disease-specific CVD emergency department (ED) visits is not well established. OBJECTIVES: This retrospective observational study aimed to assess the relationship between macroeconomic trends and CVD ED visits. METHODS: This study uses data from the National Hospital Ambulatory Care Survey (NHAMCS), Federal Reserve Economic Database (FRED), National Bureau of Economic Research (NBER), and CVD groupings from National Vital Statistics (NVS) and Center for Medicare and Medicaid Services (CMS) from 1999 to 2020 to analyze ED visits in relation to macroeconomic indicators and NBER defined recessions and expansions. RESULTS: CVD ED visits grew by 79.7% from 1999 to 2020, significantly more than total ED visits (27.8%, p < 0.001). A national estimate of 213.2 million CVD ED visits, with 22.9 million visits in economic recessions were analyzed. A secondary group including a 6-month period before and after each recession (defined as a "broadened recession") was also analyzed to account for potential leading and lagging effects of the recession, with a total of 50.0 million visits. A significantly higher proportion of CVD ED visits related to heart failure (HF) and other acute ischemic heart diseases (IHD) was observed during recessionary time periods both directly and with a 6-month lead and lag (p < 0.05). The proportion of aortic aneurysm and dissection (AAA) and atherosclerosis (ASVD) ED visits was significantly higher (p = 0.024) in the recession period with a 6-month lead and lag. When controlled for common demographic factors, economic approximations of recession such as the CPI, federal funds rate, and real disposable income were significantly associated with increased CVD ED visits. CONCLUSION: Macroeconomic trends have a significant relationship with the overall mix of CVD ED visits and represent an understudied social determinant of health.

Ecolabels and the economic recession.

We examine the effect of the 2008 economic recession on consumers' observed expenditures for eco-labelled grocery products. Traditional price theory predicts that consumers change their spending during an economic downturn and we would expect the sales share of eco-labelled products to fall since these are relatively more expensive than non-labelled products. We use supermarket loyalty card data from the UK and show that the recession had widely different effects on the expenditure share of different eco-labelled grocery products. We confirm, empirically, that expenditure shares on organic products declined over the time period under study but the expenditures share for fair-trade products increased over the same period. We evaluate alternative models of decision making to explain our results, viz., a salience model and a model of reputation signalling. We find that both of these models give a plausible explanation of our empirical results.

State-level economic uncertainty and cardiovascular disease deaths: evidence from the United States.

The relationship between economic recessions and cardiovascular mortality has been widely explored. However, there is limited evidence on whether economic uncertainty alone is linked to cardiovascular disease deaths. This study examines the association between economic uncertainty and mortality from diseases of the circulatory system in the United States. We obtained monthly state-level mortality data from 2008 to 2017 and used indices capturing economic uncertainty from national/international sources and local sources. Panel data modelling was used to account for unobserved time-invariant differences between the states. Our findings suggest that economic uncertainty is independently linked to cardiovascular mortality. Uncertainty arising from national/international sources is associated with cardiovascular deaths, whereas the respective index capturing uncertainty from state/local sources is not. Deaths respond asymmetrically with respect to uncertainty fluctuations - with high levels of uncertainty driving the association. One- and two-month lagged uncertainty levels are also associated with mortality. Several robustness checks further validate the baseline findings. Overall, economic uncertainty is an independent predictor of cardiovascular mortality which appears to act as a psychosocial stressor and a short-term trigger. Public health strategies for cardiovascular disease need to consider factors driving economic uncertainty. Preventive measures and raising awareness can intensify in periods of economic uncertainty.

A decade beyond the economic recession: A study of health-related lifestyles in urban and rural Spain (2006-2017).

The 2008 economic recession may have affected health-related indicators differently depending on the living environment. We analyze health-related indicators in Spain using data from four Spanish health surveys (2006, 2011, 2014, and 2017, 95 924 individuals aged ≥16 years). In 2006-2011, physical activity decreased among men and women, while in 2006-2017, physical activity only decreased among urban women. Daily vegetable intake, except in rural women, increased in 2006-2011 but decreased in 2006-2017 in all groups. Smoking decreased among urban women in 2006-2011 and 2006-2014 but only decreased among men, and even increased among rural women, in 2006-2017. In 2006-2017, obesity increased among men and urban women, good self-rated health status increased in all groups and flu vaccination declined. Blood pressure and cholesterol control decreased in urban women in 2006-2011 but increased in 2006-2017 in all groups, as well as mammographic and cytological control. Our findings highlight the differential impact of the economic recession on health-related lifestyles according to sex and place of residence, underscoring the need for targeted health policies to address evolving health disparities over time.

Identifying the impact of the business cycle on drug-related harms in European countries.

BACKGROUND: The evidence resulting from the analysis of the association between economic fluctuations and their impact on the substance use is mixed and inconclusive. Effects can be pro-cyclical (drug-related harms are predicted to rise when economic conditions improve), counter-cyclical (drug-related harms are predicted to rise in bad economic times) or unrelated to business cycle conditions as different transmission mechanisms could operate simultaneously. METHODS: The main aim of this study is to assess, from a macroeconomic perspective, the impact of economic cycles on illegal drug-related harms in European countries over the 2000-2020 period. To this end, the regime-dependent relationship between drug-related harm, proxied by unemployment, and the business cycle, proxied by overdose deaths will be identified. Applying a time dynamic linear analysis, within the framework of threshold panel data models, structural-breaks will also be tested. RESULTS: The relationship between economic cycles (proxied by unemployment) and drug-related harms (proxied by overdose deaths) is negative, and therefore found to be pro-cyclical. One percentage point in the country unemployment rate is predicted to reduce the overdose death rate by a statistically significant percentage of 2.42. A counter-cyclical component was identified during the 2008 economic recession. The threshold model captures two effects: when unemployment rates are lower than the estimated thresholds, ranging from 3.92% to 4.12%, drug-related harms and unemployment have a pro-cyclical relationship. However, when unemployment rates are higher than this threshold, this relationship becomes counter-cyclical. CONCLUSIONS: The relationship between economic cycles and drug-related harms is pro-cyclical. However, in situations of economic downturns, a counter-cyclical effect is detected, as identified during the 2008 economic recession.

Self-Reported Mental Health and the Demand for Mental Health Care After a Labor Market Shock: Evidence from the Spanish Great Recession.

This research examines the mental health inequalities between employed and unemployed individuals among the fluctuations over the business cycle. To analyze whether a recession affects self-evaluated mental health and consequently increases the demand for mental health care, I exploit the sudden increase of the unemployment rate in Spain during the period 2007-2009. First, I analyze the impairment of self-evaluated mental health as a consequence of the Great Recession and if it prevails during the economic recovery. In addition, I estimate if the effect on self-reported mental health is reflected in demand for mental health care. The results from an event study design show that the economic downturn increases the differences between employed and unemployed individuals in self-evaluated mental health. However, and despite the continuous improvement in unemployment, the mental health gap remained unchanged between 2014 and 2017, which could imply the persistence of some lasting impacts of the Great Recession on mental health. Nonetheless, I find a reduction in the differences of using drugs related to mental health during the period 2011-2012, when I estimate the largest inequalities in self-evaluated mental health.