The health crisis in Europe

The eurozone crisis and the accompanying increase in public debt is being used as an argument to push for privatisation, thus transforming healthcare into a marketable commodity. The following article describes the myriad pathways through which public services in healthcare are being undermined across Europe. 

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THE responses in Europe to the global economic crisis have been based on strengthening of market mechanisms, combined with the encouragement of competition between countries through reduced production costs (by lowering labour costs) and social dumping. The consequences of these measures are manifested in the form of decreasing purchasing power of the population, declining public investment and a steady breakdown of social protection mechanisms.

Available evidence clearly points to a breakdown or reversal of social security systems across Europe. Between 2008 and 2011, the unemployment rate for the European Union (EU) rose from 7.1% to 10.7%. Adverse effects on young people have been particularly prominent - by September 2012, 22.8% of economically active people between 15-24 years were unemployed.1 In 2011, more than 24.2% of the EU's population were at risk of poverty, and one-third of the poor were the 'working poor'.2

The economic crisis and the accompanying increase in public debt (i.e., debts incurred by governments) is being used as an argument to push for privatisation, thus transforming healthcare into a marketable commodity. In the beginning of the economic crisis, a World Health Organisation (WHO) report in 2009 had already warned that 'some countries are at particular risk … and these include developed countries that have required emergency assistance from the IMF [International Monetary Fund], where spending restrictions may be imposed during loan repayment'.3 A study conducted by the European Foundation for the Improvement of Living and Working Conditions in several countries across Europe depicts the myriad pathways through which public services in healthcare are being undermined across Europe.4 The study, inter alia, points to the following trends:

         Since 2007, almost all EU member states have experienced reductions in public expenditure on healthcare.

         Sections of people in most of the countries studied have experienced reduced availability of healthcare services because nearby service providers have closed due to the crisis. Some have been closed as a result of explicit, top-down government decisions. Others have closed because reduced reimbursement of the services they provided and reduced income from patients made them unviable.

         Besides budget cuts and caps, delays in receipt of public funds by healthcare providers have also been identified as an impact of the crisis that has threatened continued service delivery and thus access.

         Even where the nearest healthcare service provider has remained open and its budget was not cut, people have experienced reduced accessibility due to decreased public investment in transport or reduced ability to pay for the service.

         People have also experienced reduced availability of services because of staff cuts and limits on hiring new staff.

         In countries with social health insurance systems, unemployment has led to a loss of insurance coverage for sections not entitled to free insurance. Further in countries with health insurance systems, it has become more difficult for some groups to make health insurance contributions.

         The share of healthcare costs which patients need to pay up front for treatments has increased in many countries for several types of services.

         In several countries there is evidence of a shift in the direction of public funding and provision because people cannot afford private care anymore. This leads to greater demand for public services, a greater reliance on public funding and fewer resources for service providers.

There is mounting evidence from other sources that indicates the gravity of the health crisis, brought on by austerity measures as a response by EU governments to the economic crisis.

Greece: the face of the health crisis in Europe

In Greece, the economic recession and the austerity measures imposed in the country by the troika - European Commission, IMF and European Central Bank - triggered a sharp deterioration in the socio-economic conditions of the working class and even sections of the middle class. It is estimated that 3.9 million Greeks (out of a total population of 11 million) were living below the official poverty line by the end of 20135 and the unemployment rate stood at 27.3% in2013.6 The infant mortality rate increased by 51% between 2008 and 2011; and suicide and homicide mortality increased by 11.5% and 40% respectively between 2007 and 2010.7 Concurrently, private health expenditure in Greece decreased by 16.2% between 2008 and 2010, reflecting the inability of households, in times of crisis, to purchase health services even in a situation where the public system is crumbling.

At the same time, the demand for public healthcare services has increased since the advent of the crisis.  The growing demand on healthcare facilities is reflected in an increase of 36%, between 2008 and 2012, in the number of hospitalised patients (Greek Ministry of Health, 2012). Paradoxically, austerity measures imposed by the Greek government restricted free access to healthcare services. Restrictive policies included a decrease in funding and a downsizing of public health services, higher user fees and cost-sharing. Between 2009 and 2011, the total expenditure of the Greek Ministry of Health decreased by _1.8 billion. On the other hand, in 2011, patients spent _25.7 million on out-of-pocket payments for outpatient services in public hospitals - services that had been free at the point of use before the crisis.8 Further, from 2009 to 2011, the number of people reporting inability to visit a doctor owing to economic hardship or long waiting lists increased by almost 50%.

As health insurance coverage was available only to those who work for more than 50 days per year, it left out major sections of the population, including the unemployed, casual workers and irregular immigrants; 2.5 million people in Greece are without any form of health insurance coverage (2014 data from the Greek Ministry of Labour). The current situation points to a fundamental flaw in the way public healthcare services have traditionally been funded in Greece. Historically, the social insurance funds were linked to employment, and this worked fairly well when unemployment rates were low. However, faced with the present crisis and the huge rise in unemployment, the system is on the verge of collapse and the assets of social insurance schemes have decreased dramatically.  Clearly, there is a need to organise public health services and their financing in a manner that doesn't entirely link access to healthcare with conditions of employment.

The restructuring of public health services is being driven by conditionalities imposed on Greece as part of the austerity programme. From 2010 to 2013, 170 conditionalities related to healthcare were included in the memorandums of understanding signed by the Greek government and the troika.  These include budget caps, introduction of multiple user fees, freezing recruitment of staff, and substantial reductions in health workers' wages and in the social security funds' healthcare benefit packages.9 Also included were various measures on healthcare reforms that promote the establishment of an internal market in public health services, and ultimately lead to the privatisation of these services. 

Manifestations of the health crisis in different parts of Europe

In the UK, the government has allowed corporations to enter the arena of healthcare by implementing a series of incremental and far-reaching legal changes designed to allow the entry of capital.

In Portugal, public spending declined by 8% in 2011, after having remained stable between 2009 and 2010. The national health service is under siege; important parts of the public sector have been privatised and many health workers are losing their jobs.10 Co-payments for healthcare have gone up drastically, causing a decrease of 900,000 first-line consultations and half a million emergency consultations between January and October 2012 compared to the year before, while 'rationalisation' of medicine use has led to significant increases in cost to patients.11 A study conducted in May 2012 showed that 22.2% had reduced their health expenditures. In families where one or more members were unemployed, the figure was 39.9%. The crisis is having its most dramatic impact on mental health. Between 2011 and 2012, diagnosis of depression increased by 30% in the north of the country, and in the same period, suicide attempts grew by 47% among women, and by 35% among men.12

In Italy, the growth in health expenditure between 2000 and 2010 was the lowest among the 34 OECD countries, yet savage health budget cuts have been imposed (projected to be _25-30 billion during 2012-15). This is resulting in increased user fees, removal of healthcare benefits, reduction in specialist care and decreased access to care - particularly for vulnerable socio-economic groups.13 In 2011/12, the overall expenditure for drugs decreased by 5.6%.  While public healthcare expenditure decreased by 8%, private expenditure increased by 12.3%. A sharp increase in user fees for drugs (117.3% between 2008 and 2012) has contributed to this.14 In a recent survey, 10% had postponed surgical treatment for financial reasons and 26% reported increased expenditure for medical emergencies due to higher co-payments.15 People are shifting increasingly to the private sector, which is not surprising considering that 27% say that they have paid higher fees in the public sector compared to the fees charged by the private sector for the same service.  Even more worryingly, 41.2% of Italians now consider the national health service as a safety net for essential services, and believe that all the rest should be purchased privately, and 11 million are covered by private insurance schemes.16

In Spain, the healthcare budget has declined by 18.21% since 2009.17 Healthcare services have been cut, 53,000 health professionals have been removed from the public health system in the last three years, and user fees have been increased (including co-payments for medicines). The earlier universal entitlement to access to the public health system has been replaced by employment-based entitlement, thus excluding large population groups (e.g., approximately 900,000 undocumented migrants, who are now entitled only to emergency care and maternal and childcare). As a consequence, quality of services has declined and out-of-pocket expenditure on healthcare has increased. There is a rise in waiting lists for patients who require major procedures - in 2010, 50,705 patients were on the waiting list for surgical interventions, while in 2013 their number had increased to 89,000.  National and regional governments are using budget cut targets to force the privatisation of the Spanish healthcare system - 236 out of 550 acute care hospitals are now private.18

While the German economic model is presented as a success story, 16% of the German population live in poverty and almost five million workers have 'mini-jobs' with a monthly salary of _400. The 8% increase in employment between 1996 and 2011 is due to an increase in working hours and also related to an increase in part-time employment without social security rights;19 26% of jobs in Germany are precarious (temporary contracts, part-time jobs, etc). Eight million workers (23% of the country's workforce) lived in poverty in 2010, and this included 50% of workers with full-time jobs.20 In 1998, the poorest 50% of the population possessed only 4% of Germany's wealth and this plummeted to 1% in 2008. 

Germany has also seen one of the largest waves of hospital privatisation in Europe. Between 1995 and 2010, the proportion of private hospitals doubled while at the same time the total number of hospitals fell by 11%.21 The share of cases treated in private hospitals grew from 5.2% in 1995 to 9.1% in 2003, and further to 16.1% in 2010. 

Since the 1990s, Belgium too has cut back on investments in public healthcare infrastructure and social security. From 1997 to 2005, out-of-pocket payments for healthcare rose from 23% to 28% and this has had catastrophic effects. In 2007, about 14% of the Belgian population reported having postponed necessary care because of financial problems (compared to 8% in 1997 and 10% in 2004).22

Resistance against neoliberal reforms in Europe

Across Europe the neoliberal reforms are not going unchallenged. The moves to privatise healthcare services face resistance from both popular movements of civil society and workers in the public healthcare system. In Spain, a historic unity, linking the entire range of health professionals (doctors, nurses, health workers), has resulted in the organisation in Madrid and other regions of a huge movement, called 'marea blanca' (white tide). The movement has organised a prolonged strike and massive street protests. In the face of these struggles, in January 2014 the conservative government of the region of Madrid cancelled its planned outsourcing of management and services at six local hospitals. If implemented, the plan would have transferred six public hospitals to private healthcare management groups, adversely affecting the healthcare of 1.2 million people and the careers of 5,000 health workers.23 While this has been a small victory, marea blanca warns that the protests should not stop, since a large part of the regional healthcare services is now managed or owned by private firms.

In Portugal, since the onset of the crisis, four general strikes and a series of national mobilisations involving all sections of the population have been organised to protest against privatisation of health services. These include a strike by doctors in July 2012 which saw the participation of over 80% of health professionals,24 and street protests and demonstrationsin September 2012 by hundreds of thousands in all big cities of the country.

In the UK, several public campaigns targeted the top-down reorganisation of the National Health Service (NHS). An organisation called Keep Our NHS Public, which is a network of several local affiliates, has been at the forefront of this campaign.25 After the comprehensive reform of the NHS was pushed through by the government in 2012, a group of health professionals decided to create a new political party to challenge the health reforms at a political level. The National Health Action party is set to challenge the privatisation of the NHS and the fragmentation of care accelerated by the Health and Social Care Act, and aims to restore the NHS to a service that provides publicly funded healthcare free to all at the point of need.26

In Belgium, efforts are under way to develop a coordinated campaign against the privatisation of healthcare. The Action Platform for Health and Solidarity brings together trade unions and grassroots organisations.27 It is also an endeavour to unite the resistance to neoliberal reforms in the health sector at a European level (Brussels being the main seat of the European Commission). In February 2014, the Platform organised a day of protest followed by an international conference of the European Network against Privatisation and Commercialisation of Health and Social Protection. The Platform has released a campaign manifesto against the privatisation of healthcare and for the promotion of a comprehensive, non-commodified healthcare system based on equal access.28

In Germany, 'Blockupy' protests - promoted by radical anti-capitalist political groups and networks - took place mainly in Frankfurt in 2012 and 2013 and are poised to continue, drawing increasing participation every year.29

A rising tide of protests, demonstrations and mobilisations confronted the planned dismantling of the public health system in Greece. Massive gatherings laid siege to administrative offices of public hospitals, protesting against the levy of a _5 registration fee for outpatients. In March 2014, primary healthcare doctors, administrative personnel and patients 'occupied' several primary healthcare centres to protest against the closure of 380 units by the Health Ministry. In parallel, solidarity movements were assembled to protect the growing number of jobless people who were being excluded from public health insurance schemes, and solidarity clinics were organised all over the country. These clinics combined solidarity and mobilisation of both health workers and patients against the policies denying healthcare access to millions of people.

Solidarity in the midst of crisis

The evidence from post-crisis Europe, especially as regards the major changes that have taken place in healthcare services, is a clear reminder of the need to defend public services. It is precisely at this juncture - when the economic crisis in Europe is eroding the livelihoods of millions of people - that public investment in education, healthcare and infrastructure needs to be ramped up. The question may be asked: who would pay for enhanced investment in social protection measures? In large parts of Europe the public debt is extremely high and mounting. Yet there remain islands of extreme affluence within Europe - 3.2 million families have a combined wealth of _7.8 trillion.  A tax on the financial wealth of the richest 2% could yield _100 billion every year.

There are moments in history when social logic must take precedence over other considerations. Europe stands at the crossroads today. Large parts of the continent stand to lose the benefits of social security that were won through many decades of struggles waged by the working people. To argue for a health 'commons' is to guide health workers and activists towards new ways of engagement and resistance, of participation in the struggle to protect and animate the public sphere.  As noted by Stuckler and McKee: 'There is an alternative: public health professionals must not remain silent at a time of financial crisis.'30               

Compiled by Amit Sengupta, the above draws, among other sources, from chapters in Global Health Watch 4: An Alternative World Health Report (2014, available at www.ghwatch.org) contributed to by Alexis Benos, Angelo Stefanini, Chiara Bodini, Dirk van Duppen, Egmont Ruelens, Elias Kondilis and Pol de Vos. Global Health Watch 4 is produced by People's Health Movement, Medact, Medico International, Third World Network, Health Action International and Asociacion Latinoamericana de Medicina Social, and published by Zed Books.

Endnotes

1      Alatalo, J., J. Furuberg, H. Gustavsson et al. (2013). A sketch of youth unemployment in selected countries. Nuremberg: Institute for Employment Research, 30 July.

2      Algemeen Belgisch Vakverbond (ABVV) (2012). Sociaal-economische barometer 2013. December.

3      World Health Organisation (2009). The Financial Crisis and Global Health: Report of a High-Level Consultation. World Health Organisation, Geneva, 19 January; Information Note/2009/1, 21 January.

4      Eurofound (2014). Access to healthcare in times of crisis. Publications Office of the European Union, Luxembourg.

5      Stevens, R. (2013). Greek strikes continue as unemployment, poverty hit record levels. World Socialist website, 16 February

6      Dabilis, A. (2013). Greece unemployment stays at 27.3%. Greek Reporter, 14 November.

7      Ibid.

8      Kondilis, E., S. Giannakopoulos, M. Gavana et al. (2013). Economic crisis, restrictive policies, and the population's health and health care: the Greek case. American Journal of Public Health, 103(6): 973-979.

9      Ibid.

10    Augusto, G.F. (2012). Cuts in Portugal's NHS could compromise care. The Lancet, 379(9814): 400.

11 Campos, A. (2013). Taxas moderadoras nas urgncias podem subir para 40 euros.  Publico, 9 January.

12 Observatrio Portugus dos Sistemas de Sade (OPSS) (2013). Duas Faces da Sade, Relatrio de Primavera 2013. Coimbra: Mar da Palavra Ed.

13    Costa, G., M. Marra, S. Salmaso and Gruppo AIE su crisi e salute (2012). Gli indicatori di salute ai tempi della crisi in Italia [Health indicators in the time of crisis in Italy]. Epidemio logia & Prevenzione, 36(6): 337-366.

14    Instituto Nazionale di Statistica (ISTAT) (2013). Annual Report 2013: The State of the Nation. Rome, 22 May.

15 Freni Ricerche Sociali e di Marketing (2011). Comportamenti in materia di spese sanitarie davanti alla crisi economica. Florence.

16    Instituto Nazionale di Statistica (ISTAT) (2013). Annual Report 2013: The State of the Nation. Rome, 22 May.

17    The Economist (2013). Is Spain on the verge of a public health-care crisis? 16 December.

18    European Network against Privatisation and Commer-cialisation of Health and Social Protection (2014). Health and Social Protection Are Not for Sale!: Manifest of the European Network against Privatisation and Commercialisation of Health and Social Protection. Brussels, 7 February.

19    Algemeen Belgisch Vakverbond (ABVV) (2012). Sociaal-economische barometer 2013. December.

20    Bosch, G. (2012). Prekre Beschftigung und Neuordnung am Arbeitsmarkt: Expertise im Auftrag der Industriegewerkschaft Metall. IAQ-Standpunkt, Institut Arbeit und Qualifikation, Universitt Duisburg-Essen, September.

21    Destatis (2013). Annual Report 2012. Wiesbaden: Federal Statistical Office.

22 Organisation for Economic Cooperation and Development (OECD) (2007). Health at a Glance 2007: OECD Indicators. Paris: OECD Publishing.

23    Marcos, J. (2014). Madrid abruptly cancels plans to outsource management at public hospitals. El Pas, 27 January.

24    Soares, M. (2012). Medicos dizem ter feito a maior manifestaao de sempre. Publico, 11 July.

25    Keep Our NHS Public (n.d.).

26    The Lancet (2012). A new UK political party to fight for the NHS. The Lancet, 380(9856): 1792.

27    Sant & Solidarit (Plate-forme d'action Sant & Solidarit) (n.d.).

28    European Network against Privatisation and Commerciali-sation of Health and Social Protection (2014). Health and Social Protection Are Not for Sale!: Manifest of the European Network against Privatisation and Commer-cialisation of Health and Social Protection. Brussels, 7 February.

29    Blockupy (n.d.)., accessed 6May 2014.

30    Stuckler, D. and M. McKee (2012). There is an alternative: public health professionals must not remain silent at a time of financial crisis. European Journal of Public Health, 22(1): 2-3.

*Third World Resurgence No. 296/297, April/May 2015, pp 38-42