Eurofound (2014) Access to healthcare in times of crisis, Eurofound Surveys: EF14421, 31 October.
Research Project by Eurofound, where the Crisis Observatory also participated by examining Greece as a case study. The aim of the research programme was to record the impact of the crisis on citizens’ access to health services as well as to highlight best practices and initiatives that can be applied in the administration of health services’ units during the crisis…
The research team constisted of the following scientists: Dimitris Katsikas (Head of the Crisis Observatory), Maria Zafiropoulou, Health Issues Expert in the European Commission (and member of the Observatory Plus team), Charalampos Economou, Assistant Professor at the Department of Sociology of the Panteion University of Social and Political Sciences, Daphne Kaitelidou, Assistant Professor in the Department of Nursing (University of Athens), and Olga Siskou, Head Researcher at the Center for Health Services Management and Evaluation (University of Athens) as well as deputy national representative in the Health Committee of the OECD.
In the wake of the crisis, many European governments have cut spending on healthcare services. However, in the face of rising unemployment and financial strain, there is an increased need for some healthcare services, while decreased disposable income has made access to healthcare more difficult for many households in the EU. In this context, policymakers and service providers are faced with the challenge of maintaining access to healthcare services. This report explores which population groups have experienced reduced access to healthcare as a result of the crisis. It presents examples of measures taken by governments and service providers to maintain access for groups in vulnerable situations. The report is the final output of Eurofound’s project on the impacts of the crisis on access to public healthcare services, and builds on an earlier working paper providing evidence from data analysis and a literature review. It draws on nine in-depth country studies, and on 31 case studies, carried out in 11 Member States.
Along with effective prevention and social protection policies, access to high-quality healthcare services can reduce health inequalities, social exclusion and poverty, key objectives of the Europe 2020 strategy. At the same time, timely access to healthcare can prevent higher healthcare costs in the long run, increase productivity of the workforce and facilitate people’s active participation in society, as emphasised in the European Commission’s Social Investment Package. Furthermore, access to healthcare under the conditions established by the Member States is recognised as a fundamental right of the European Union.
While the crisis has been a major factor influencing complex healthcare systems, there are significant differences between countries and between services in the impact the crisis has had on healthcare access. Nevertheless, even where a country’s health services have hardly experienced any cuts (such as all services in Luxembourg, and nursing home healthcare in Latvia), it has still been possible to identify impacts of the crisis on access to healthcare. Access to healthcare for groups in vulnerable situations
Difficulties in accessing healthcare have long been more common among certain population groups. In some cases, measures facilitating access for these groups have been cut. While there is great heterogeneity within these groups, they include people living in countries with poor overall access or in remote areas; those with low health literacy, poor education and low incomes; people with greater healthcare needs in general (such as people with disabilities, elderly people and people with chronic illnesses); or those who belong to a specific disadvantaged ethnic minority (such as Roma), as well as homeless people and migrants.
The crisis has resulted in the emergence of new groups that were not considered vulnerable previously due to increased unemployment, especially among young men, and increased household debt problems, particularly for young couples facing housing and job insecurity. People have found themselves in more vulnerable situations because of the crisis, particularly those who have experienced:
- reduced disposable income;
- loss of a job or benefit that came with insurance;
- the ‘twilight zone’ – being marginally beyond the threshold for which social support measures apply;
- new situations, to which the entitlement system has not adjusted or where the person is unaware of entitlements;
- need for a service for which coverage has been reduced, which has been particularly affected by cuts or which has experienced staff shortages;
- need for a service for which demand has increased significantly;
- closure of nearby healthcare providers;
- discrimination due to an increase in xenophobia.
Most service providers in the case studies reported a range of responses to sustain access during the crisis, including economising, seeking funds from other public sources, and leniency in enforcing copayments for people in need. Some governments have sustained or expanded coverage and exemptions from copayments for population groups affected by the crisis. Other strategies identified in the research include:
- accelerating trends of deinstitutionalisation, reducing hospital stays and keeping older people in
- the community, combined with development of an alternative care infrastructure;
- retaining and motivating staff, drawing on less costly workers, and work reorganisation;
- seeking new funding sources from alliances with local actors;
- ensuring basic services, such as scaled-down replacement services, when a service provider is
- closed; group sessions for patients with crisis-related mental health problems; self-help, medical
- helplines or e-healthcare for people in remote areas; basic information packages;
- scaling up screening and measures to prioritise most urgent needs and services.
Policymakers and service providers need to be aware of the unexpected or indirect consequences of cuts and reduced disposable income on access to services. In some countries, demand for nursing home care has declined because the pensions of elderly relatives are an important source of household income (Hungary, Latvia). In some cases, people have moved from private to public healthcare creating increased demand (Greece, Ireland, Slovenia), while in others private hospitals have gained more clientele (Bulgaria, Romania, Sweden) partly as an indirect consequence of the crisis.
Simple cost-cutting solutions may incur higher costs in the longer term. It is important to be wary of increased use of emergency and inpatient care. In some countries, inpatient care has increased because family members cannot afford to keep patients at home (Bulgaria and Slovenia) or because of cuts in outpatient care (Ireland). In other cases, demand for emergency care has increased because it is cheaper to access, payments due from patients are less likely to be collected, there is no nearby non-emergency care, or the facilities are open at more convenient hours (Bulgaria, Greece, Ireland and Sweden).
In addressing the challenge of maintaining access in the context of the crisis, policymakers and service providers may consider:
- integrating mitigating measures into cost-cutting policies, rather than reacting to problems after reforms are implemented;
- determining whether incremental responses to the new situation – creating a complex network of exemptions – may be worse than overhauling the system as a whole;
- recognising that investing in the working conditions of healthcare staff, apart from salaries, can be an effective option to tackle staff shortages;
- developing alternative care infrastructures when deinstitutionalisation and reduced reliance on inpatient care have been accelerated;
- making investments in the short run, for example, in ICT, self-help facilities, and home and ambulatory care, to free up resources in the longer term;
- recognising that while ‘leniency’ of service providers allows access for people in vulnerable situations free of charge, it risks unequal treatment and unreliability especially in times of crisis;
- but lessons can be drawn from locally identified needs for leniency;
- combining formal exemptions and entitlements with effective implementation;
- nurturing and communicating the importance of alliances with local stakeholders;
- reassessing all cost-saving measures implemented during the crisis once financial pressure is reduced.
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