Crisis, Austerity and Health Inequalities in Southern European ...

e-cadernos CES

31 | 2019Crisis, Austerity and Health Inequalities inSouthern European CountriesMauro Serapioni et Pedro Hespanha (dir.)

Édition électroniqueURL : http://journals.openedition.org/eces/4043DOI : 10.4000/eces.4043ISSN : 1647-0737

ÉditeurCentro de Estudos Sociais da Universidade de Coimbra

Référence électroniqueMauro Serapioni e Pedro Hespanha (dir.), e-cadernos CES, 31 | 2019, « Crisis, Austerity and HealthInequalities in Southern European Countries » [Online], posto online no dia 15 junho 2019, consultadoo 15 março 2020. URL : http://journals.openedition.org/eces/4043 ; DOI : https://doi.org/10.4000/eces.4043

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SOMMAIRE

Artigos

Crisis and Austerity in Southern Europe: Impact on Economies and SocietiesMauro Serapioni et Pedro Hespanha

Challenges to Healthcare Reform in Crisis-Hit GreeceMaria Petmesidou

The Impact of Austerity on the Portuguese National Health Service, Citizens’ Well-Being, andHealth InequalitiesPedro Hespanha

The Lasting Effects of a “Relentless Crisis”: The Great Recession and Health Inequalities inSpainJuan Antonio Córdoba-Doña et Antonio Escolar-Pujolar

Crisis, salud y calidad de vida. Algunas evidencias en España y PortugalElena Cachón González

Contexto económico y determinantes sociales de la accidentabilidad laboral en el sur deEuropa. Los casos portugués y españolRaúl Payá Castiblanque

The Italian National Health Service after the Economic Crisis: From Decentralization toDifferentiated FederalismStefano Neri

Access to Healthcare and the Global Financial Crisis in Italy: A Human Rights PerspectiveRossella De Falco

@cetera

Sistema Único de Saúde: redução das funções públicas e ampliação ao mercadoTânia Regina Krüger

Debate sobre os fundamentos do conservadorismoRosana Mirales

e-cadernos CES, 31 | 2019

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Artigos


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Crisis and Austerity in SouthernEurope: Impact on Economies andSocietiesCrise e austeridade no Sul da Europa: impacto nas economias e sociedades

Mauro Serapioni and Pedro Hespanha

1 Since Richard Titmuss’s seminal work on the welfare state and social policy (Titmuss,1958, 1974), there have been concerns with the detection and understanding of thediversity of existing welfare state models and of the functions of social policy in orderto define the relevant options for decision-making. More recently, Esping-Andersen(1990), in his research on the political economy of the welfare state in advancedcapitalist societies, empirically confirmed the validity of Titmuss’s typology for a broadset of the Organisation for Economic Co-operation and Development (OECD) countries,and refined its conceptual framework through the theoretical attributes of de-commodification, social stratification, and welfare mix. By renaming his own typologyas the three worlds of welfare capitalism, this author associates to a certain extent ageographical dimension to the political dimension (liberal, conservative or social-democratic) of each regime by using the USA as an example of the Anglo-Saxon world;Germany of the continental European world; and Sweden of the Scandinavian world.

2 The impact of this typology on subsequent studies has been enormous, some of themclaiming that other groups of countries do not fit properly in Esping-Andersen’s trilogyand that they therefore represent a flagrant gap to be filled. This is the case of theSouthern European countries (SEC) that joined the European Union later – that is,Greece, Portugal and Spain – and which, according to several authors, represent,together with Italy, a different world of welfare – the Latin-rim or Mediterraneanmodel (Ferrera, 1996; Leibfried, 1992; Andreotti et al., 2001; Silva, 2002; Karamessini,2008) – which is framed by a particular historical and socio-political context. One of theoutstanding attributes of the welfare state in these countries, particularly suitable forhealth systems, is their universalist approach. In fact, all of these four countries, in thefinal phase of the expansion of their welfare states between the 1970s and 1980s


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created their own national health services (NHS) with universal access inspired in theBeveridgean model established in the United Kingdom in 1948. Among the commonaspects of these Southern European NHS the following should be mentioned: (i)inconsistency between the universal promises and the effective response given tocitizens’ needs due to limitations in the process of implementation of national healthservices, in particular financial constraints (Giarelli, 2006); ii) difficulties in themanagement of the public system that led governments to introduce reforms aiming toimprove efficiency, namely by following the rules of new public management (Cabiedesand Guillén, 2001); iii) the importance of non-professional human resources, such asfamily and primary care networks to compensate for the NHS’s deficiencies (Santos,1987; León and Migliavacca, 2013); iv) lack of participation by the users’ representativesin decisions about health policy and in the organization of health services (Matos andSerapioni, 2017).

3 Despite these limitations, the four countries have significantly improved healthindicators thanks to the social and economic development of the last decades and thecontinuous improvement of health care. However, these indicators, which are generallyvery positive, conceal situations of great inequality both in the distribution ofeconomic and social resources and in the access to health services. At critical times,inequalities widen and larger groups of citizens are affected. This is precisely whathappened during the recent financial crisis of 2008 in these four Southern Europeancountries, which soon became a systemic – economic, social, and political – crisis(Laparra and Pérez Eransus, 2012).

4 Due to inequalities between Eurozone economies, crises may affect only some of themand spare the others, with the Economic and Monetary Union (EMU) common rule notapplying in such cases. On the contrary, EMU contributes both to the reinforcement ofinequalities, i) when promoting the specialization of economies in productions in whichthey have higher relative efficiency and ii) when removing from Member States thepossibility of using important economic and monetary instruments, such as thereduction of interest rates, currency devaluation, or public expenditure increase.

5 What seems to be particularly distinctive in this crisis is that, thanks to the existence ofa monetary system that imposes strict limitations on the use of traditional crisismanagement tools, the room for government maneuver has been greatly reduced in sofar as the supervision of supranational institutions is concerned. In turn, for thoseunder financial assistance the imposition of adjustment programs eventually came tocontrol their sovereignty.

6 The creditors’ own preferred solution – austerity rule – has been adopted against therisk of worsening the financial crisis even by those Member States which did not haveto resort to financial assistance, as in the case of Italy. Austerity rule has contours thatare not well defined and may have quite different interpretations. In a nutshell, itrefers to a set of economic and social policies by which governments aim to halt orreduce public expenditure. We would also highlight the fact that these options allowfor the “modification of the State’s redistributive policy and of the expenditure relatedto the functioning of the economy and social reproduction” (Ferreira, 2014: 117).1

7 Damages caused by austerity policies to the economies and societies of countries whichhad to adopt them showed in different forms. From early on, decrease in the GDP oreven deep recessions (Table 1) with serious future implications occurred, not only dueto investment halt and sovereign debt increase (Table 2), but mainly as a result of social


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consequences: job destruction and increase in unemployment (Table 3); precariousness,especially in younger segments of the economically active population; large emigrationflows of qualified workers; and the worsening of poverty, social exclusion (Table 4) andincome inequalities (Table 5). Table 1 – GDP Growth Rate (%): Greece, Portugal, Spain, Italy and Eurozone (2008-2014)

2008 2009 2010 2011 2012 2013 2014

Greece -0.3 -4.3 -5.5 -9.1 -7.3 -3.2 0.7

Portugal 0.2 -3.0 1.9 -1.8 -4.0 -1.1 0.9

Spain 1.1 -3.6 0.0 -1.0 -2.9 -1.7 1.4

Italy -1.1 -5.5 1.7 0.6 -2.8 1.7 0.1

Eurozone 0.5 -4.5 2.1 1.6 -0.9 -0.2 1.4

Source: Eurostat (2018).

TABLE 2 – Sovereign Debt (% of GDP): Greece, Portugal, Spain, Italy and Eurozone (2008-2014)

2008 2009 2010 2011 2012 2013 2014

Greece 109.4 126.7 146.2 172.1 159.6 177.4 178.9

Portugal 71.7 83.6 96.2 111.4 126.2 129.0 130.6

Spain 39.5 52.8 60.1 69.5 85.7 95.5 100.4

Italy 102.4 112.5 115.4 116.5 123.4 129.0 131.8

Eurozone 68.7 79.2 84.8 86.9 89.9 91.8 92.0


TABLE 3 – Unemployment Rate (%): Greece, Portugal, Spain, Italy and Eurozone (2008-2014)

2008 2009 2010 2011 2012 2013 2014

Greece 7.8 9.6 12.7 17.9 24.5 27.5 26.5

Portugal 8.8 10.7 12.0 12.9 15.8 16.4 14.1

Spain 11.3 17.9 19.9 21.4 24.8 26.1 24.5

Italy 6.7 7.7 8.4 8.4 10.7 12.1 12.7


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Eurozone 7.6 9.6 10.2 10.2 11.4 12.0 11.6


TABLE 4 – At-Risk-of-Poverty or Social Exclusion* Rate (%) (2008-2014) Greece, Portugal, Spain, Italyand Eurozone

2008 2009 2010 2011 2012 2013 2014

Greece 28.1 27.6 27.7 31.0 34.6 35.7 36.0

Portugal 26.0 24.9 25.3 24.4 25.3 27.5 27.5

Spain 23.8 24.7 26.1 26.7 27.2 27.3 29.2

Italy 25.5 24.9 25.0 28.1 29.9 28.5 28.3

Eurozone 21.7 21.6 22.0 22.9 23.3 21.1 23.5

* People in one of the following conditions: at-risk-of-poverty after social transfers (income poverty),severely materially deprived or living in households with very low work intensity.Source: Eurostat (2018).

TABLE 5 – Inequality of Income Distribution Ratio (S80/S20*) (2008-2014)Greece, Portugal, Spain, Ireland and Eurozone

2008 2009 2010 2011 2012 2013 2014

Greece 5.9 5.8 5.6 6.0 6.6 6.6 6.5

Portugal 6.1 6.0 5.6 5.7 5.8 6.0 6.2

Spain 5.6 5.9 6.2 6.3 6.5 6.3 6.8

Italy 5.2 5.3 5.4 5.7 5.6 5.8 5.8

Eurozone 4.9 4.9 4.9 5.0 5.0 5.1 5.2

* S80/S20 – ratio of total income received by the 20% of the population with the highest income (thetop quintile) to that received by the 20% of the population with the lowest income (the bottomquintile).Source: Eurostat (2018).

8 The comparative analysis of austerity policies effects in four countries severely affectedby the crisis (Greece, Portugal, Spain, and Italy) shows that, although the range ofavailable political instruments is limited and not very diversified, the way in whichthey are combined and implemented is crucial to explain the different effects austeritypolicies had in each country.

9 Table 6 summarizes the measures adopted by these four countries. It should be notedthat only two of them (Greece and Portugal) were under a very heavy financial


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assistance program, contrary to what happened in Spain where the intervention wasnot in the form of a sovereign debt relief but of a program of assistance for therecapitalization and restructuring of the banking sector. The same applies to Italy,where the possibility of requesting an emergency loan in order to overcome thesovereign debt crisis was seen as the “point of no return” for the stability of the euroarea in its entirety. As the Eurozone’s third largest economy, Italy was considered “toobig to fail, too big to bail” (OXFAM, 2013). TABLE 6 – Under the Austerity Rule (2008-2010): The Main Reforms in Policies in Greece, Portugal,Spain and Italy

Greece Portugal Spain Italy

Increase in individualincome tax rates, partiallycompensated by decreasingtax rates for lower bands;

Changes in the fiscalbenefits and bonuses

Widening of thecontributory basis.

Increase inindividual incometax rates;

Introduction of anadditional tax ratefor top earners;

Reduction of fiscalbenefits.

Introduction of anadditional incometax rate for topearners.

Increase in individualincome tax rates;

Reintroduction of ahousing property tax.

Cuts in public pensions;

Introduction of a one-offadditional tax on incomesand a special tax onpensions.

Freezing of nearlyall social insurancebenefits andpensions.

Freezing of publicpensions.

Reform of the pensionsystem, raising theretirement age forwomen and men.

Deep cuts in socialspending at national andlocal level

Increase on VAT taxes.Increase on VATtaxes.

Increase on VATtaxes.

Increase on VAT taxes.

Cuts in public sector wages.Cuts in public sectorwages.

Cuts in public sectorwages.

Source: Adapted from Callan et al. (2011) and OXFAM (2013).

10 Without going into further detail, the differences regarding the implementation ofausterity rule are evident, as well as the similarities between the policy instrumentsused. With regard to the structural adjustment programs agreed with the Troika in thehealth sector, it is worth recalling the factors triggering the financial crisis and theproblems that led three Southern European countries (Greece, Portugal and Spain) tobe submitted to a readjustment programme.

11 In the case of Greece, the expansion of the internal demand between 2000 and 2009,when the Gross Domestic Product (GDP) growth rate was higher than that of theEurozone, determined a fast growth of bank credit demand (especially for expenseswith durable consumer goods, including housing) favored by low interest rates. As aconsequence, foreign commerce registered an increasing negative balance whereas


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competitiveness levels deteriorated, at the same time that public administrationexpenditure expanded; this resulted in the aggravation of the annual deficit in publicaccounts, which reached the peak of 14% of the GDP in 2008, and a sovereign debt of115% of the GDP in 2009 (European Commission, 2010). This was the earliest case ofexternal intervention, which occurred in May 2010; it is also accounts for the longestongoing intervention, with a second rescue program starting in June 2012 in the formof a partial debt relief, and a third program starting in August 2015 (EuropeanCommission, 2012, 2015)

12 In Portugal there were similar causes: accumulation of high external debts in previousyears by the State as well as by families or firms. The growing demand for externalfinancing for public debt and banking investment originated a strong interest rateincrease in the financial markets along with a rating degradation of the Portuguesesovereign debt and bank solvency.

13 The adjustment program started in May 2011 and lasted until mid-2015 (EuropeanCommission, 2014). There are two aspects to be highlighted in the Portuguese case forthe assessment of the reforms: firstly, since 2009, before entering the program, thegovernment had implemented a set of measures to combat the crisis – Stability andGrowth Programs I, II and III – basically consisting of public expenditure reduction;secondly, the right-wing coalition government, which had the responsibility forimplementing the adjustment program agreed with the Troika used the opportunity toimpose its own agenda, clearly of a neoliberal character, moving further than thesettled goals by means of reinforced austerity measures (Table 7). TABLE 7 – The Adjustment Programs in Greece, Portugal and Spain

Greece Portugal Spain


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2010 (May 2nd): Firsteconomic adjustmentprogram in the amount of€80 billion euros to bereleased during be periodfrom May 2010 to June2013.

2012: Second economicadjustment program in theadditional amount of €130billion euros for the years2012-2014; later postponeduntil the end of June 2015.

2015 (August 19th): Thirdeconomic adjustmentprogram in the amount of€86 billion euros infinancial assistance from2015 through 2018.

2011 (May 17th): The economic adjustmentprogram in the amount of €78 billioneuros, during the period of 2011 tomid-2014, to re-establish access tofinancial markets, enabling the recovery ofthe economy to sustainable growth and tosafeguard financial stability in Portugal, inthe Eurozone and in the EU.

2012 (July 23rd): Theeconomic adjustmentprogram in the amount of€100 billion euros forrecapitalization and re-structuring of the Spanish financial sector.

Source: Hespanha, 2017.

14 In the case of Spain, the intervention was not made by means of a sovereign debt relief,but rather through a financial assistance program for the recapitalization andrestructuring of the banking system. The decapitalization of banks followed the burstof a construction industry bubble in 2008 and the deep involvement of banks infinancing that sector. Reforms undertaken by the Spanish government wereinsufficient to reduce the pressure of financial markets and the stress levels of banks;this forced the Spanish government to request financial assistance in 2012 (EuropeanCommission, 2012).

15 The Memorandums of Understanding (MoUs) subscribed by the governments ofcountries subjected to financial aid comprise a set of measures specifically directed atthe health sector, along with other transversal measures aiming to reduce publicexpenditure that equally affected this sector. Our analysis will focus on these measures.

16 The main remark to be made when comparing the general objectives of the MoUs isthat Troika’s ‘recipes’ did not differ much and concentrated on a limited amount ofobjectives, somehow hindering the adaptation to the specificities of each country ineconomic, social and political terms, and making it necessary for governments and theTroika to maintain permanent negotiations. On this issue two ideas should be added: a)Troika’s attitude was or has been quite rigid in the sense that it did not easily acceptthe alternatives offered by the national governments for the attainment of the sametargets; b) each of these three countries received a different treatment regarding themargin of flexibility consented by the Troika. For example, in the case of Spain therewas no such detailed program concerning the measures to be implemented in order toreach the goals (European Commission, 2012).


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17 Therefore, the main axes of the health sector reform the three countries had incommon concerns control of public expenditure and improvement of the servicesefficiency and effectiveness, including the promotion of a more rational use ofresources and services, such as, for example, the reduction of the fragmentation ofservices or the dispersion of their tutelage (Table 8).

18 Vigorous external pressures for economic policy change were exerted in all SEC.Although Italy did not sign a MoU, the EU’s involvement in defining economic policieswas significant during the sovereign debt crisis between 2011 and 2012. In order tohave the support of the European Central Bank, Italy engaged in a series of structuralreforms, accepting the ‘implicit conditionality’, an instrument used by the EuropeanUnion during the Eurozone crisis and “based on an implicit understanding of the stakesand sanctions involved […], even in the absence of detailed covenants” (Sacchi, 2015:77, 79). Even if the Monti government identified pension and labour policy as the mainissues that could be submitted to reforms, other sectors were also affected. Among theausterity policies implemented in the Italian health sector, it is worth mentioning thefollowing (Dirindin, 2011; Ferré et al., 2014; Maciocco, 2015):

Increased co-payment for medicines, out-patient care and non-necessary emergencyadmissions;Reduction of the number of hospital beds from 4 to 3.7 per 1.000 inhabitants;Reduction of expenditure on health-care personnel;Reduction in the prices of pharmaceuticals, increase in use of generic drugs and decrease inpharmacy revenue;Reduction in the expenditure caps on purchasing medical equipment and services.

TABLE 8 – General Objectives of the Adjustment Policies in Health in Greece, Portugal and Spain

Greece Portugal Spain

General objectives:

- Control public expenditure andincrease efficiency, cost-effectiveness and equity of thesystem;

- Stimulate savings by means of amore rational use of resources;

- Concentrate all institutions andpolicies related to health underthe responsibility of the Ministryof Health.

General objectives:

- Improve efficiencyand cost-effectiveness;

- Stimulate a morerational use of healthservices;

- Control publicexpenditure inhealth.

General objectives:

- Implement reforms in the publicsector to improve the efficiency and thequality of public expenditure in all ofgovernmental levels;

- Integrate the funds in order tosimplify a highly segmented system;

- Concentrate measures related tohealth under one ministerialcoordination.

Source: Hespanha, 2017.

19 The average annual rate of contraction of public health expenditure in the SEC between2009 and 2017 has been significant. According to the OECD it was more pronounced inGreece, followed by Spain, Italy, and Portugal (Table 9). In the same period, themajority of the countries of other European macro-regions have maintained the normalrate of growth in public health expenditure (Germany, France and Sweden), or haveregistered smaller decreases (Czech Republic, Poland and Hungary), with the exception

•

• • •

•


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of Great Britain and Ireland, which suffered a substantial reduction (5.1% and 4.5%respectively) (Serapioni, 2018).

Table 9 – Evolution of Public Health Expenditure (2009-2017) as % of Total Spending in the SEC

2009 2010 2011 2012 2013 2014 2015 2016 2017 Differences

Greece 68.5 69.1 66.0 66.5 62.1 58.2 58.3 61.3 61.2 -7.3%

Portugal 69.9 69.8 67.7 65.6 66.9 66.1 66.2 66.4 66.6 -3.3%

Spain 75.4 74.8 73.8 72.2 71.0 70.4 71.3 71.2 70.8 -4.6%

Italy 78.3 78.5 77.0 76.1 76.1 75.6 74.6 74.5 74.0 -4.3%

Source: OECD – Health Statistics, 2018.

20 Several studies have highlighted the effects of the crisis on health systems in SouthernEuropean countries, particularly on the most vulnerable social groups, leading, forinstance to an increase in mental disorders as well as in suicides (De Vogli, 2014). Theseeffects have already been observed in Greece, Ireland, Italy, Portugal and Spain(Karanikolos et al., 2013; Ruiz-Pérez et al., 2017), i.e. in countries where austeritypolicies have been imposed or vigorously recommended (Petmesidou et al., 2014), andinvolved “blind cuts and disqualification of services” (Hespanha, 2017: 95). The increasein health inequalities, both social and geographical, is also one of the side effects of thestructural adjustment policies applied in the SEC (Escolar-Pujolar et al., 2014; Guillén etal., 2016).

21 This thematic issue of e-cadernos CES gathers contributions from scholars andresearchers who have dealt with the relationship between crisis, austerity policies andNHS reforms on the one hand, and the growth of health inequalities on the other. Inthe first article, Maria Petmesidou presents the slow and tortuous process forreforming the health system in Greece from the early 1980s until the outbreak of thecrisis in 2008. In this context, the author analyses how, under the pressure of thesovereign debt crisis, the shift in institutional and power relations has forced politicalactors to recognize the functional limits of the health system and to accept theimplementation of a set of policy measures and regulatory instruments that formed thebasis of reform. In the second part, the article illustrates the main reforms defined inthe Troika rescue package and then examines the impact of such measures. Among theexpected results of the reform, the author emphasizes the unification andrationalization of health insurance, in order to oppose the fragmentation of the healthsystem and the inequalities of coverage and access. At the same time, however, theauthor notes that the contraction of financial and human resources has dramaticallyreduced the scope, quantity and quality of the services provided, as well as increasinglyunmet medical needs, especially among the most vulnerable social groups, thusdeepening inequalities in terms of accessibility.

22 The case of Portugal is analysed by Pedro Hespanha by debating the guidelines of themain health reforms carried out or planned in Portugal to ensure the financialsustainability of the health system since 2010; Hespanha concludes from distinct


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evidence that, although most of the health reforms would be useful and necessary,those implemented produced negative and somehow unforeseen consequences due totheir short-run duration and their universal-based design. In the absence of a well-structured reform program, the blind application of cuts on expenses prevailed,regardless of the impact these cuts would cause on very sensitive areas of medical care.The manner in which slowness, insufficiency or downgrading of services affectscitizens differs according to their social condition and the ways in which they deal withthe situation. Hence, health inequalities were kept consistently higher than thoseobserved in other European countries in the last decade and continue to be closelyassociated with socioeconomic factors.

23 The article by Juan Antonio Córdoba-Doña and Antonio Escolar-Pujolar reviews themain findings on the impacts of the crisis on health inequalities in Spain. The authorsfirst present a historical background of the Spanish National Health System (SNHS),from the dictatorship period through the democratic era, until the latest recession.Then, they look into the implemented austerity policies and their effects on the publicspending on health as well as the privatisation and dismantling of the SNHS, focusingespecially on citizens' responses to austerity measures. The widespread discontent andthe civic indignation against neoliberal austerity policies are considered by the authorsas the most remarkable episodes of social mobilization in defense of the welfare state inSpain since the introduction of democracy and maybe the strongest bulwarks againsthealth inequalities. The second part of the text reviews almost exhaustively theacademic literature and official data on the impact of the 2008 crisis on healthinequalities, to conclude that the SNHS displayed considerable resistance to the effectsof recession during the early years but its buffer capacity was exhausted by 2013,aggravating social inequalities and disproportionately affecting the most vulnerablepopulations.

24 Two articles compare the cases of Spain and Portugal. Elena Cachón González analysesthe impact of the crisis and austerity on health inequalities, combining objectiveindicators on health and health services with subjective indicators on quality of liferelated to health and also on the individual satisfaction with health services. The datashows that, although the objective indicators have improved once the crisis wasovercome, the same did not occur with the subjective indicators because, among otherreasons, the social determinants of health are still far from normal. Raúl PayáCastiblanque in turn, is particularly concerned with the effect of the crisis and austerityon the increasing rates of work accidents and the unequal ways in which this affectsdifferent groups in the active population. Two categories of workers are particularly hitin both countries: those in precarious sectors in the areas of construction and theindustry, and those in small enterprises, especially young people.

25 The case of Italy is scrutinised in two different articles, one by Stefano Neri, the otherby Rossella De Falco. Stefano Neri examines the process of reform of the NationalHealth Service (NHS) since the beginning of the 2008 crisis, with an aim to focus on thechanges to NHS governance. The author illustrates the characteristics of the Italianhealth system and the main stages of the decentralization process from the State to theregions, highlighting the changing of their respective roles and the operation of theState-Region Conference, a mechanism of joint policy making between the centralgovernment and the regions. Neri also analyses the repercussions of the economiccrisis on intergovernmental relations, explaining how the crisis strengthened the role


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of the central government (namely, the Ministry of Economy but indirectly also theEuropean institutions) in the development of national policies, to the detriment of therole played by the regions. For the author, this change in intergovernmental relationscould endanger the universalist nature of the Italian NHS and its capacity to guaranteethe values of equity and solidarity, especially on a geographical level. From theperspective of human rights, Rossella De Falco studies the impact of post-2008 austeritypolicies on increasing inequalities in the Italian National Health Service. Afterdescribing the fiscal adjustments implemented by the government, the authorexamines key right-to-health indicators over the 2010-2016 period. Finally, based onthe analysis of secondary data from national and international sources, De Falcofocuses on the increasing level of unmet medical needs due to costs, waiting time, andincreased user fees. The results, the author argues, evince how the regressive healthpolicies undermine equitable access to care.

26 To expand the reflection on the South initiated with the case of the SEC, the @ceterasection presents two articles from the perspective of the global South (Santos, 2018),namely Brazil. These texts address the impact of neoliberal and conservative reformsimplemented in recent years. The text by Tânia Krüger, entitled “Sistema Único deSaúde: redução das funções públicas e ampliação ao mercado”, illustrates thedeconstitutionalization of the Unified Health System (SUS) as a result of the process ofdismantling and privatisation of public health institutions and services. The authorexamines the recent counter-reforms hitting the SUS, presenting indicators that showhow it is becoming subordinate to the private health sector.

27 Rosana Mirales’s essay focuses on 21st century conservative thinking and its negativeimpact on both social services and professional training in this field of intervention.Mirales looks into Josep Bacqués’s recent study El liberalismo- conservador. Fundamentosteóricos e recetario político ss. XVIII-XX with an eye to developing a critical analysis of thefoundations of conservatism and its close ties to liberalism.

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Guillén, Ana M. González Begega, Sergio; Luque Balbona, David (2016), “Austeridad y ajustessociales en el Sur de Europa. La fragmentación del Modelo de Bienestar mediterráneo”, RevistaEspañola de Sociología, 25(2), 261-273.

Hespanha, Pedro (2017), “As reformas dos sistemas de saúde na Europa do Sul: crises ealternativas”, in Paulo Henrique Rodrigues; Isabela Santos (eds.), Políticas e riscos sociais no Brasil ena Europa: convergências e divergências. Rio de Janeiro: HUCITEC Editora, 81-110.

Karamessini, Maria (2008), “Continuity and Change in the Southern European Social Model”, International Labour Review, 147(1), 43-70.

Karanikolos, Marina; Mladovsky, Philipa; Cylus, Jonathan; Thomson, Sarah; Basu, Sanjay;Stuckler, David; Mackenbach, Johan; McKee, Martin (2013), “Financial Crisis, Austerity, andHealth in Europe”, The Lancet, 381, 1323-1331.


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https://ec.europa.eu/info/sites/info/files/01_mou_20150811_en1.pdf

https://ec.europa.eu/info/sites/info/files/01_mou_20150811_en1.pdf

https://ec.europa.eu/eurostat/web/national-accounts/data/main-tables




Leibfried, Stephan (1992), “Towards a European Welfare State”, in Zsuzsa Ferge; Jon EivindKolberg (eds.), Social Policy in a Changing Europe. Boulder: Westview Press, 245-279.

León, Margarita; Migliavacca, Mauro (2013), “Italy and Spain: Still the Case of Familistic WelfareModels?”, Population Review, 25(1), 25-42.

Maciocco, Gavino (2015), “Assalto finale al Servizio Sanitario Nazionale”, Salute Internazionale,October 26. Accessed on 30.05.2019, at http://www.saluteinternazionale.info/2015/10/assalto-finale-al-servizio-sanitario-nazionale/.

Matos, Ana Raquel; Serapioni, Mauro (2017), “O desafio da participação cidadã nos sistemas desaúde do Sul da Europa: uma revisão da literatura”, Cadernos de Saúde Pública, 33(1).

Laparra, Miguel; Pérez Eransus, Begoña (coord.) (2012), Crisis y fractura social en Europa. Causas yefectos en España. Barcelona: Obra Social “la Caixa”. Série: Estudios Sociales n. 35.

OECD – Organisation for Economic Co-operation and Development (2018), Health Statistics. Frequently requested data. Paris: OECD Publishing.

OXFAM – Oxford Committee for Famine Relief (2013), “The True Cost of Austerity and Inequality.Italy Case Study”. Accessed on 12.05.2019, at https://www-cdn.oxfam.org/s3fs-public/file_attachments/cs-true-cost-austerity-inequality-italy-120913-en_0.pdf.

Petmesidou, Maria; Pavolini, Emmanuele; Guillèn, Ana M. (2014), “South European HealthcareSystems under Harsh Austerity: A Progress-Regression Mix?”, South European Society and Politics,19, 331-352.

Ruiz-Pérez, Isabel; Bermudez-Tamayo, Clara; Rodríguez-Barranco, Miguel (2017), “Socio-economic Factors Linked with Mental Health During the Recession: A Multilevel Analysis”, International Journal for Equity in Health, 16, article 45.

Sacchi, Stefano (2015), “Conditionality by Other Means: EU Involvement in Italy’s StructuralReforms in the Sovereign Debt Crisis”, Comparative European Politics, 13(1), 77-92.

Santos, Boaventura de Sousa (1987), “O Estado, a sociedade e as políticas sociais: o caso daspolíticas de saúde”, Revista Crítica de Ciências Sociais, 23, 13-74.

Santos, Boaventura de Sousa (2018), O fim do império cognitivo. A afirmação da epistemologia do Sul.Coimbra: Almedina.

Serapioni, Mauro (2018), “L’impatto della crisi nei sistemi sanitari dei paesi mediterranei”, Sociologia Italiana. AIS Italian Sociology, 12, 187-201.

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NOTES1. All the translations have been made by the authors.


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https://www-cdn.oxfam.org/s3fs-public/file_attachments/cs-true-cost-austerity-inequality-italy-120913-en_0.pdf




ABSTRACTSThis article discusses the economic and social impact of the 2008 crisis and its related austeritypolicy on South European countries (SEC). Damages caused by these policies includes thedecrease in GDP, the increase in unemployment and precariousness, especially amongst theyounger population, and the worsening of social services. SEC health systems have also beenseriously affected by the crisis, with a particular impact on the most vulnerable social groups, asa result of the decrease in public health expenditure. The increase in health inequalities isanother side effect of the structural adjustment programs.

Este artigo analisa o impacto social e económico da crise de 2008 e das políticas de austeridadedela derivadas nos países do Sul da Europa (PSE). Os danos causados pelas políticas deausteridade incluem a diminuição do PIB, o aumento do desemprego e da precariedade,especialmente entre a população mais jovem e a degradação dos serviços sociais. Os sistemas desaúde dos PSE também foram seriamente afetados pela crise, atingindo particularmente osgrupos sociais mais vulneráveis, como resultado da redução da despesa pública em saúde. Oaumento das desigualdades na saúde é outro efeito colateral dos programas de ajuste estrutural.

INDEX

Palavras-chave: crise, desigualdades de saúde, países do Sul da Europa, sistemas de saúdeKeywords: crisis, health inequalities, health systems, South European countries

AUTHORS

MAURO SERAPIONI

Centro de Estudos Sociais da Universidade de CoimbraColégio de S. Jerónimo, Largo D. Dinis, Apartado 3087, 3000-995 Coimbra, [email protected]

PEDRO HESPANHA

Centro de Estudos Sociais da Universidade de Coimbra | Faculdade de Economia da Universidadede CoimbraColégio de S. Jerónimo, Largo D. Dinis, Apartado 3087, 3000-995 Coimbra, [email protected]


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mailto:[email protected]


Challenges to Healthcare Reform inCrisis-Hit GreeceDesafios à reforma dos cuidados de saúde na Grécia afetada pela crise

Maria Petmesidou

EDITOR'S NOTE

Received on 13.12.2018Accepted for publication on 02.05.2019

1. Introduction

1 Greece has suffered the most severe consequences of the crisis that followed the globalfinancial meltdown of 2008. The country went through an eight-year program ofexternal financial assistance by the European Commission (EC), the European CentralBank (ECB) and the International Monetary Fund (IMF), the so-called Troika, inexchange for strict austerity measures and structural adjustment across a largespectrum of policy areas. A moderate economic recovery in 2017 and 2018,accompanied by a limited fall in the unemployment rate (from 25% in 2015 to about19% in late 2018), is a positive development. Yet the economy is still in dire straits.Sovereign debt amounts to around 180%of Gross Domestic Product (GDP) – the highestin the European Union (EU) – and it remains 25% lower than its pre-crisis peak.1

Moreover, post-bailout commitments for exorbitant fiscal primary surpluses in theyears ahead will deprive the economy of serious resources in the road to recovery. OnAugust 20, 2018 Greece formally exited its bailout program. Yet as the country is highlyindebted to the European official sector (close to €260 billion), “enhanced” surveillanceby the international lenders will continue (IMF, 2018; EC, 2018a). Compared to the otherEuro area countries that went through a financial bailout, in Greece post-program


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surveillance will be of higher frequency (on a quarterly basis) and the monitoring ofspecific policies stricter.2

2 For a long time, the Greek healthcare system was stuck halfway between a highlyfragmented social health insurance and a national health service model. In the early1980s a universalist national health system ESY (Ethniko Sistima Ygeias) wasintroduced. However, until lately, the ESY hardly reached the state of a fully-fledgednational health service. Both in terms of funding and service delivery a mixed systemcontinued to operate: an occupation-based health insurance system combined with anational health service, but private provision was expanding too (mostly out-of-pocketpayments as private health insurance remained negligible). The economic and financialcrisis that engulfed the country as well as strong outside pressure by the internationallenders brought reform, along the lines of the “path shift” introduced in 1983, high onthe agenda. This precipitated changes, such as the unification of health funds, thestandardization of contributions and the equalization of the benefits package acrosssocio-occupational groups. Yet, at the same time, rising user charges, rolling back ofpublic provision, and rationing through increasing waiting times and other blockagemechanisms have a negative impact on access, equity and service quality.

3 We start our analysis by briefly laying out an explanatory framework for the“incomplete reform” until the eruption of the crisis and the window of opportunitythat has emerged since then for pursuing system rationalization and consolidation.Then, we critically discuss the major reforms that took place over the last decade.These are examined along two core dimensions of health systems: a) the funding andallocation of financial resources to providers, and (b) the structure and governance ofprovision. A major question addressed is whether the ongoing reforms can enhanceand sustain universalism, or instead do they contribute to the withering away of apublic system, which, anyway, never in the past embraced strong universalisticprinciples. Corroborating evidence of a bleak future is manifested by data on increasinginequalities in healthcare regarding accessibility to and affordability of health services.

2. The Crisis as Catalyst: An Analytical Context

4 Two analytical accounts of policy reform are illuminating for understanding: a) whythe path shift towards a national health system has for a long-time remained a half wayreform in Greece, and b) which dynamic underlies the attempts to complete the reformin the last few years, though amidst severe fiscal retrenchment. These consist inThelen’s conceptualization of “institutional layering” (2004), and Kingdon’s analysis of“windows of opportunity” for policy breakthroughs (1995).3

5 As extensively shown in the social policy literature, institutional arrangements arecharacterized by a considerable “stickiness”. They consolidate interests andcommitments that create “veto” points, which highly increase the political (and oftenalso the economic) cost of change (see Pierson, 1996; also Wilsford, 1994 on “Pathdependency”). Critical junctures due to economic and/or political crises providewindows of opportunity for major reforms. However, for this to happen there needs tobe an alignment favorable to change between three components: actors, institutionsand ideas. Namely, there needs to be problem recognition by actors, willingness/abilityto act and availability of policy ideas (Kingdon, 1995). Furthermore, as Thelen (2004: 35)has shown, incremental change, particularly in the form of “institutional layering”


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(that is, adding a new “layer” on an otherwise stable institutional setting) can be adriver of transformation too, particularly in the long run. Under certain conditions, ifthis “layering” process takes place in a prolonged period it can “significantly alter theoverall trajectory of an institution’s development” (ibidem).

6 In the realm of health politics and policy, in Greece, three reform efforts are of crucialimportance: a) the introduction of ESY in the early 1980s; b) a failed attempt to revivereform momentum for completing the shift towards a national health system in theearly 2000s; and c) a crisis-driven reform under the bailout program.

7 A few years after the restoration of democracy in the country, the introduction of anational health system took place at a critical juncture consisting in the rise to power,for the first time, of a socialist party (the Panhellenic Socialist Movement Party –PASOK), in 1981. The way the reform fared reveals the obstacles to wholesale change.As shown elsewhere (Petmesidou, forthcoming):

Path-dependent institutional factors hindered the government’s willingness/abilityto pursue the breakthrough initiated by Law 1397 of 1983 that established ESY.PASOK consolidated its dominant position in the Greek political system byeffectively rebuilding/expanding clientelist relations, a condition that hardlyallowed even a minimum consensus among social actors about how to articulateredistributive issues along the lines of universalist citizenship values and criteria.

8 Hence, a watered-down version of the reform was implemented. This was a politicallyexpedient solution as the government was confronted by strong veto points within themedical profession and the privileged health insurance funds (mostly sickness funds ofemployees in public banks, telecommunications and other public enterprises).

9 Major stipulations in the law, such as uniform funding and service provision for allcitizens, the gradual absorption of the private by the public sector, and a morebalanced regional distribution of health infrastructure and personnel remained largelyon paper, and the reform did not significantly change the status quo in healthinsurance. Universal access was limited to hospital care. Primary care was neglected,largely provided by the private sector, the health centers of IKA (the Social InsuranceOrganization for the majority of private sector employees), as well as by medicalpractitioners contracted by various sickness funds. Private spending continued to rise,and many privileged health insurance funds maintained their prerogatives. Thus, quitesoon after the proclamation of a radical reform, social policy returned to its oldpatterns. Following Thelen (2004), we would argue that the reform added “a new ‘layer’(universalist healthcare) onto an existing stable institutional framework (a splinteredhealth insurance system)” (Petmesidou, forthcoming). In the context of a politicaldynamics heavily relying on statist/clientelist practices, instead of this processtriggering a momentum of policy breakthrough over time, it sustained a “disjointedpattern” with low degree of institutional coherence and prevalent path-dependentfeatures, over the following two decades (ibidem). Diversity of coverage, multiplicity offunding and system fragmentation persisted and accounted for lack of coordination ofpurchasing policies, soaring ESY deficits, alarmingly rising pharmaceutical expenditureand other system predicaments. At the turn of the century, an initiative by the Ministryof Health, under the then PASOK government, to tackle fragmentation, rationalize andde-concenter decision-making and control, and regulate relations between key healthactors met strong opposition from various quarters, even within the government. Thiscaused the resignation of the Minister of Health and the downsizing of reformambitions.


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10 The deep economic and financial crisis significantly reshuffled political relationships.Strong outside pressure by the country’s international lenders made it imperative forthe government to push through reforms, in tandem with harsh cuts in funding andreceding public provision. Under the bailout program a (more or less forced) alignmentbetween the three spheres mentioned above – institutions, actors and ideas – hasoccurred. This created a window of opportunity that made long-overdue reformspossible (Petmesidou, forthcoming). Amidst a severe economic and financial crisis, theresources for clientelist exchanges significantly diminished, the legitimacy of politicalparties, trade unions and other major political actors waned, and the party systemexhibited a deep systemic crisis (Petmesidou, 2017: 157). Moreover, the bailout dealimposed an upward shift in decision-making for major reforms to the internationallenders (and mainly to the crisis-management apparatus of the EU). The role of theexecutive was strengthened, while the ability of trade unions, associations, and other“veto” groups to sway political decisions significantly weakened (Petmesidou andGlatzer, 2015: 170-176). Moreover, the bailout conditions allowed the government toshift the blame of reform and austerity to the Troika, in order to shield itself frompolitical risk. Importantly, a pool of policy measures and regulatory instruments(among others, e-prescribing, diagnosis protocols, closed-budgets of health units, etc.)provided the constitutive elements of the reform. These were advocated by the EC, theIMF and the World Health Organization (WHO), which played a crucial role in guidingpolicy. The combination of the above factors facilitated a coupling of the three majorstreams in policy. Namely, under the sovereign debt crisis, the shift in the power anddecision-making dynamics forced political actors to recognize the system’s functionaldeficits, made imperative for them to act, and set the policy options.

3. The Reform Trajectory

3.1. Trends in Health Expenditure – Main Dimensions of Reform

11 Soaring deficits by public hospitals and rapidly increasing pharmaceutical expenditureover the 2000s greatly strained the state budget. In the decade prior to the eruption ofthe crisis, per capita total health expenditure (measured in constant Purchasing PowerParities, PPPs) grew on average annually by about 6.6% (EU15 average: 3.6%;Petmesidou, forthcoming). Markedly, average yearly per capita private spending rosefaster than public spending (by 7.7 and 5.8% respectively). Especially high was the rateof growth of per capita pharmaceutical spending: 11.1% yearly on average (in constantPPPs) during the 2000s (average for the other three South European countries: 1.3%;ibidem).4 Nevertheless, in 2009, per capita public health expenditure (in constant PPPs)was about a third lower of the EU15 average. Yet private spending exceeded thecorresponding rates for the EU15 and the other three South European countries (TableI).

12 Deep spending cuts took central stage in Greece’s Economic Adjustment Program (EAP)under the successive bailout packages. So did also some key issues, which have beendebated since the inception of ESY in 1983, but never materialized, such as devolution,integration of primary and secondary care, reduction of fragmentation in healthinsurance, etc. The changing demographic makeup is also a matter of concern asGreece is set to experience rapid ageing in the coming decades: the share of the


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population aged over 65 years from about 20% in 2015 is estimated to reach 35% in 2060(among the highest rates in the EU; EC, 2018b: 191). Together with fast medicaltechnology advancement and rising expectations for quality provisions and choice,population ageing will increase pressure on public spending (particularly on chronicdiseases and geriatric and personal care).5

13 Strict ceilings were set in the EAP for total public health financing and its constitutiveschemes – for instance, total public health spending is capped at (or below) 6% of GDPand pharmaceutical expenditure at about 1% of GDP, which however has shrunk by aquarter since 2010, as mentioned above. From 2009 to 2017 total health spending (incurrent prices) dropped from €22.5 billion to €14.9 billion and public spending(government and compulsory social health insurance) almost halved (from €15.4 to €9.1billion).6 This is a rather steep contraction compared to the other three South Europeancountries, which have also implemented austerity programs (for instance in Portugal,in 2017 public health spending in current prices was only about 6% lower than its peakrate in 2009). TABLE I – Health Indicators

Per capita expenditure (constant PPPs, OECD base year*)

2009-2013 2017

Greece Portugal Spain Italy EU15 Greece Portugal Spain Italy EU15

Total healthexpenditure

2826/1960

2651/2340

2885/2722

3103/2965

3860/3936

2015 2515 2981 3033 4084

Public healthexpenditure

1937/1218

1854/1566

2175/1933

2430/2255

3055/3054

1233 1676 2110 2245 3186

Private healthexpenditure

889/726

798/774

710/789

673/710

804/881

781 839 871 788 899

Totalexpenditure onmedical goods**

834/567

635/461

639/620

588/

588

686***/623

625 474 674 625 642

Publicexpenditure onmedical goods**

648/337

351/229

306/229

313/322

436***/370

367 231 324 353 391

Average yearly change of per capita expenditure (constant PPPs, OECDbase year*)

2009-2013 2013-2017

Greece Portugal Spain Italy EU15 Greece Portugal Spain Italy EU15

Total healthexpenditure

-8.7 -3.1 -1.4 -1.1 0.5 0.7 1.8 2.3 0.6 1.7


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Public healthexpenditure

-11.0 -4.1 -2.9 -1.8 0.0 0.3 1.7 2.2 -0.1 1.1

Private healthexpenditure

-4.9 -0.7 2.7 1.3 2.1 1.9 2.0 2.5 2.6 0.5

Totalexpenditure onmedical goods**

-9.3 -7.7 -0.8 0.0 - 3.3 0.9 2.8 1.6 1.0

Publicexpenditure onmedical goods**

-15.1 -10.2 -6.3 0.7 - 2.9 0.3 1.2 2.4 1.8

Notes: *Constant prices (2010), constant PPPs (2010), in US dollars.** Mostly pharmaceuticals (for Greece, Portugal, Spain and EU15 most recent data for expenditure onmedical goods refer to 2016). *** EU average in 2009 excludes Ireland and the UK due to missing data.Source: OECD Health Data and own elaboration. Accessed on 30.10.2018, at https://stats.oecd.org/Index.aspx?ThemeTreeId=9.

14 Between 2009 and 2013, per capital public health spending, in real terms, contracted by11% on average annually, and stagnated afterwards. Thus, in 2017 per capita totalhealth spending dropped to about half that of the EU15, and per capita publicexpenditure to a third of the respective EU15 average (Table I). Equally sharp has beenthe decline of per capita public spending on medical goods (mostly pharmaceuticals, inPPPs and constant prices).

15 Private spending (out-of-pocket – including informal – payments and private healthinsurance premiums, the latter of limited importance though) stood at €7.1 billion in2009 (Figure I). It decreased until 2012, but it then resumed a slight upward trend,despite falling household incomes until recently. In 2016, private spending amountedto about 40% of total health spending, compared to about 30% in the other three SouthEuropean countries, and to 24% in EU15 (Figure II). Taking also into account thepersistently low degree of satisfaction with public health services (Petmesidou et al.,2014: 333-335; Eurofound, 2017: 54-56), extensive reliance on private spending highlyquestions whether a truly universal system has ever been in place in Greece.


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https://stats.oecd.org/Index.aspx?ThemeTreeId=9




FIGURE I – Health Care by Financing Scheme (2009-2016, Current Prices)

Note: The amount of government financing for 2018 is taken from the State budget.Source: ELSTAT health data. Accessed on 30.10.2018, at http://www.statistics.gr/en/statistics/-/publication/SHE35/-.

FIGURE II – Percentage Constitution of Health Care Financing

Note: SE = average for Spain, Italy and Portugal.Source: Petmesidou, forthcoming.

16 The crisis intensified financial, organizational and equity problems that characterizedhealthcare in the country for several decades. Most importantly, great diversity in therange and quality of provisions among the plethora of sickness funds kept inequalityhigh.7 Since 2011, in the context of the reform dynamics briefly highlighted above, anumber of measures have been introduced, apparently in order to tackle major systemdeficiencies. However, a controversial trend is clearly manifest. Steps are taken


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http://www.statistics.gr/en/statistics/-/publication/SHE35/-




towards the completion of the transition to ESY and system rationalization. But large-scale public health spending cutbacks and a range of policy options are shifting the costaway from the State and impose significant barriers of access to and use of care.Strikingly, at the level of rhetoric, the framing of the reform stresses the need for deepcuts as a way to keep the publicly operated system afloat, yet a shift towards a“universalism” of basic provision looms large (Petmesidou et al., 2014: 345).

17 On the funding side, a major structural reform consists in the separation of the healthfrom the pension branches of social insurance funds and the merging of the formerinto a unitary organization (the National Health Services Organization, Greek acronymEOPYY, legislated in 2011), to act as a single purchaser of health services. This wasaccompanied by the equalization of contributions and the standardization of the healthbenefits basket across occupational groups. Also, mechanisms of monitoring andcontrol of services were put in place, facilitating a tighter spending oversight. Changesin the allocation arrangements, by which funding is transferred to services providers,were also implemented, particularly regarding hospital payment systems.

18 On the organizational/governance side, consolidating hospitals into larger units, re-configuring cost-accounting and management, as well as integrating primary andsecondary care have been varyingly implemented so far. Of significant importance is athree-year plan to overhaul primary care, which started being rolled out in 2018. Theaim is to create a gate-keeping system with the establishment of first contact,decentralized local health units, which will guide patients, through referral procedures,to the second tier of ambulatory care and to inpatient care.

19 The Greek health system has persistently been highly centralized. Despite theestablishment of Regional Health Authorities (YPEs in the Greek acronym) in the early2000s, plans to devolve responsibility for the operation and management of healthunits failed to materialize. Recent reforms disclose a two-way trend: The pooling ofhealth insurance contributions through the creation of EOPYY indicates a movetowards centralization, while the assignment of control over primary care to YPEspoints in the direction of decentralization. However, it remains to be seen whether thelatter move will be backed by the devolution of real decision-making power. 3.2. Funding Side Changes: How Healthcare Revenue Is Raised andAllocated to Service Producers

20 Health financing derives from three sources: taxation – over 50% of it being indirecttaxes in 2017 (Independent Authority for Public Revenue, 2017: 2 and 6) –, socialinsurance contributions and private, mostly out-of-pocket, spending. Between 2009 and2016, we observe a significant change in the composition of healthcare financing withthe sharp drop of the health funds’ share from about 40 to 29% and the increase of out-of-pocket payments to over a third (Figure II above). Rising unemployment andinability to pay contributions by a significant number of self-employed and smallbusinesses account for the decline of health insurance revenues. Moreover, extensivereliance on out-of-pocket payments and indirect taxation renders the system highlyregressive.

21 From 2011 to 2016, the amalgamated pension branches of social insurance funds wereresponsible for collecting contributions, which then were transferred to EOPYY. In2017, this function was undertaken by a new body (the Unified Body of Social


24

Insurance, Greek acronym EFKA,) responsible for the collection of health and pensioninsurance contributions. EOPYY should maintain a balanced budget, as state subsidy ishenceforth confined to the organization’s operational costs (around 0.4% of GDP;Economou et al., 2017: 56; see also Karakolias and Polyzos, 2014).8

22 While the health insurance funds were under the jurisdiction of the Ministry of Labour,Social Insurance and Welfare, EOPYY came under the authority of the Ministry ofHealth. Initially the organization was also responsible for the management of primarycare (the healthcare centers previously belonging to the health insurance funds). But in2014, a split took place between insurance-purchasing functions retained by EOPYY,and primary and ambulatory care provision undertaken by a new organization, theNational Primary Healthcare Network (PEDY, the Greek acronym). Potentially, as thesingle purchaser of publicly provided healthcare services, EOPYY could weigh heavilyon bargaining with suppliers. But its powers are greatly limited as decisions rest withthe Ministry of Health in a context of highly centralized collective bargaining withsuppliers’ associations.9

23 The State budget covers the salaries of health and administrative personnel in publichospitals, primary/ambulatory care in local health units, health centers and outpatientdepartments, and capital investment. It also provides subsidies to public hospitals andEOPYY, as mentioned above. Services offered by public hospitals are paid by EOPYY,until 2013 on a fixed per person, per diem basis, and since then on the basis ofdiagnostic related groups (DRGs). EOPYY also funds service provision by contractedphysicians, private diagnostic laboratories and clinics.

24 Regulatory mechanisms introduced include: a) budget ceilings for EOPYY accompaniedby a clawback/rebate mechanism for private providers (pharmacies, pharmaceuticalcompanies, diagnostic laboratories and private clinics) so as to keep expenditure withinthe budget limits;10 and b) thresholds on physicians’ activity (limits in the number ofreferrals for diagnostic tests, compulsory prescribing by active substance, andelectronic monitoring).

25 The introduction of e-governance tools and attempts to make the public procurementsystem more transparent and efficient are also among the main cost-containmentmeasures. However, in the absence of systematic health needs assessment at differentlevels (e.g. regional, local), caps on referrals and prescriptions per specialty (andprefecture), in place in the last few years, are drawn in a rather ad hoc way. Forinstance, according to a recent Ministerial Circular11 average monthly per capitaprescription rates for pathologists range from €34 to €45, while for forensic surgeons,who seldom issue prescriptions, the rate is set at about €55. Equally unfounded on anysound evidence of demographic and morbidity trends is the fluctuation of rates perprefecture/per month. The obvious aim is a further cut in the value of physicians’prescriptions in tandem with the doubling of the generics share from about 20 to 40%.

26 Co-payments for pharmaceuticals more than doubled, from about 10 to 25% (plus anextra charge of €1 per prescription), and a 15% co-payment for diagnostic andlaboratory tests in contracted centers was introduced. Exemptions from co-payments(or lower rates) apply to individuals and families with very low income (including theuninsured with low income) and some vulnerable groups (e.g. people with chronicdiseases) on the basis of income criteria.12 At the same time, existing exemptions fromuser charges for some groups were lifted. For instance, for the chronically ill personsexemptions are strictly related to their chronic illness, even though some of their


25

ailments maybe an indirect consequence of their health conditions (Petmesidou, 2014:20).

27 Other major measures for lowering prices and volumes of pharmaceuticals embrace theestablishment of a drug-pricing observatory and a reference pricing system that setsthe rates on the basis of the average price of the three lowest-priced markets in the EU;the introduction of a positive (and negative) list for reimbursement purposes; thereduction of the profit margin for pharmacies; and ceilings in physicians’ prescriptions,as stressed above.

28 An entrance fee of €3 for outpatient care, introduced in 2010 (and increased to €5 in2011), as well as a €5 fee charged for every hospital admission since 2014, wereabolished in 2015. But private outpatient clinics, run within public hospitals in theafternoon, charge fees per visit, which, however, are not covered by social insurance. Inthe last few years, the rising number of visits to afternoon clinics of public hospitals isthe result of long waiting lists for free access to specialists. Also, since 2012, patientswho receive treatment in private hospitals/clinics contracted by EOPYY must pay 30%of the total cost.

29 Informal payments have persistently been a major component of out-of-pocketpayments keeping private spending high and exacerbating inequalities in care. Theyare common for skipping waiting lists and as undeclared cash payments to physiciansand surgeons. Comparatively low salaries of ESY health personnel in Greece vis-à-visother EU countries, further reduced during the crisis, partly account for this behaviour.Strikingly, a rough estimate by Liaropoulos (2010) sets the size of the black economy inthe health sector (defined as the aggregate of “graft, fraud and under-the-tablepayments” in the public and private sector) at about €4 to €5 billion annually, duringthe decade of the 2000s. This should total approximately €50 billion in the end of thedecade, an astonishing amount that is equal to the cumulative public deficit from 2003to 2009 (ibidem). Even though this estimate should be taken with caution, it provides aglaring indication of the serious inefficiencies of the healthcare system. Nevertheless, itis worth noting that, despite measures for combating systemic problems, and thestrains on household incomes during the crisis, the practice of under-the-tablepayments continues unabated. A survey conducted in 2012 “reports under-the-tablepayments for approximately 32.4% of public hospital admissions” (Souliotis et al., 2016:159), and an equally high percentage (36%) of undeclared fees paid for visits to privatepractitioners and dentists (ibidem; see also Liaropoulos et al., 2008).

30 In a nutshell, considerable improvements in rationalizing funding accrue to the poolingof resources, the establishment of a single payer, the shift from retrospectivereimbursement for secondary health service provision (based on the patient cost perspecialty) to a case-mix payment, and a raft of strict monitoring policies for doctors.Yet, policy wise, a systematic allocation of resources across the country on the basis ofneed, drawing upon demographic, socio-economic and epidemiological data has hardlybeen in place. YPEs could potentially play a crucial role in developing needs assessmentmechanisms, provided their budgetary and planning competences are strengthened. AHealth and Welfare Map to monitor health needs, allocation and use of resources thatcould feed into policy decision-making has been on the agenda of the Ministry ofHealth since the early 2000s, but with very little progress so far.


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3.3. Institutional/Organizational Arrangements in Service Provision

31 Organizational reform embraces: a) a two-way trend of centralization/decentralizationof administrative and governance functions and controls, and b) a consolidation ofsecondary care providers into larger units.

3.3.1. A Two-Directional Trend

32 The split trend along the first dimension consists, on the one hand, in: the pooling offinancial resources through the establishment of EOPYY (and, later on, of EFKA); thecentralization of decision-making and control over the range of service provision andresource allocation methods; and the ongoing trend of centralized procurement ofmedical supplies and devices so as to reduce less-than-optimal outcomes and improvetransparency. Also, new information systems – such as electronic platforms forcollecting/monitoring data on performance – accompany centralization policies ofgovernance. Though, so far, these do not embrace any quality indicators and qualityassurance strategies.

33 On the other hand, legislation for primary care enacted in 2014 transferredresponsibility for primary care coordination to regional health authorities. The lawprovided for the redrawing of the primary care map by creating a mixed-system ofproviders embracing the about 200 hundred rural surgeries (transferred from ESY toPEDY), the urban primary healthcare units (ex-IKA units transferred to EOPYY in 2012,and to PEDY in 2014), and contracted physicians and private laboratories. However, thenetworking plan was hardly implemented. A significant reduction of the medical staffin the ex-EOPYY health centers considerably limited public service provision. Thereduction in staffing levels was caused by the change in the employment conditions formedical doctors under PEDY. Physicians employed in the ex-EOPYY units were asked tochoose whether to become full-time employees in the National Primary HealthcareNetwork and close down their private practice, or else terminate their participation inthe system. Medical doctors of ex-EOPYY health units strongly opposed the reform bill,demanding that full-time work conditions be in force only for new appointments inPEDY, while those who served under IKA and EOPYY for over 15 years be allowed theoption of combining private practice with provision of services in PEDY units until theyretire. Eventually the reform bill turned into law, as this was a policy stipulated by thebailout package, and a significant number of physicians of urban health centers chosenot to join the new organization.

34 In 2017, new legislation passed by the coalition government between SYRIZA (Coalitionof Radical Left) and ANEL (Independent Greeks, a small, far-right populist party) addeda further layer of primary services, the so-called Local Units of Primary Care (TOMYs,in the Greek acronym), planned to operate as gate-keepers to the system andstrengthen primary prevention and health promotion activities. Under the new plan,PEDY units will function as a second-tier ambulatory care. TOMYs, together withcontracted private physicians (general practitioners, pathologists and pediatricians)will establish a local gate-keeping network, targeting family doctor services for all.Once more, an attempt is made to integrate primary care into the public system andcounteract overreliance on specialist and inpatient care. However, the implementationof the plan is beset with problems. The time-span of budgetary provision for theoperation of TOMYs is limited (up to four years maximum) and funding is tied to EU


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sources. Besides, adequate infrastructure is hardly available in many localities.Similarly, to other services relying on EU sources (e.g. the Home Help program), thereis the risk of service discontinuity when EU funding stops. These uncertainties accountfor the low response by doctors (even junior ones facing unemployment) to repeatedcalls by the Ministry of Health for filling positions in TOMYs.13 Equally difficult has beenso far to attract private practitioners to the local primary care network, to becontracted family doctors. Significant changes in EOPYY’s contract conditions (lowerearnings for higher workload and restrictions on private practice) met with thereluctance of private practitioners to join the planned primary healthcare network. Asstressed in a recent report (EC, 2018c: 36), “slow progress may increase the risk offuture discontinuation or reversal”. 3.3.2. Consolidation of Secondary Care Providers

35 Re-configuration of secondary healthcare service providers has been on the way duringthe last few years with the aim to contain cost and rationalize structure andgovernance. Policy measures embrace the redrawing of the hospitals map, bycombining them into fewer units under common administration, the cutting downand/or rearrangement of clinics and functional beds, changes in the function of severalESY healthcare facilities, staff relocation and redistribution of heavy equipment acrosshospitals. However, so far, these policies have limited implementation, and accordingto a recent study their positive effect on overall hospital efficiency has not beensignificant (Kaitelidou et al., 2016). Efficiency improvement is also sought by measuressuch as the introduction of a double-entry accounting system for costing services, theall-day functioning of hospitals, extension of working hours of outpatient offices, andthe revision of emergency and on-call duty.

36 Notably, staff shortages have intensified, due to hiring freeze for several years, andpersistent reliance on term-contract appointments of health personnel. Mostimportantly, the shortage of nursing staff seriously affects service delivery – in some ofthe main hospitals in Athens cutbacks have left one nurse to look after 20 or morepatients (Petmesidou, 2014: 19). Greece ranks last among the EU28 countries in terms ofthe ratio of nurses per 1,000 population (3.2 in 2014, EU28 average 8.4). Staff shortagesalso affect intensive care units, some of them operating below their capacity(Economou et al., 2017: 78). According to WHO standards, 9 to 12% of functional hospitalbeds must be in intensive care units. In Greece, the rate is close to 2%, while over a fifthof them are not in operation due to qualified staff shortages.14 Overall, major challengesremain with regard to the deployment and management of resources, coordinationwith primary care, response to need, and quality of services.

4. Inequalities of Healthcare: Accessibility andAffordability

37 Austerity-driven cuts and reforms cast doubts on the “universal” character of thesystem. Equalization of provision across social insurance funds was accompanied by asignificant review of the range of public provision, leading towards a low commondenominator. This shifted provision to the private sector and, in tandem with


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significant inequalities in the geographical distribution of public health facilities,greatly impacted upon accessibility to and affordability of healthcare.

38 Importantly, the crisis conditions brought to the fore the serious problem of a rapidlyincreasing number of uninsured people. In 2013, it was estimated by EOPYY(Petmesidou et al., 2014: 345) that there were about 2.5 million people lackinghealthcare coverage. These included the long-term unemployed and their dependents,people who filed business bankruptcy, or who might still run a business but wereunable to pay contributions due to severe hardship, and legal/illegal immigrants andrefugees. In 2013, a program was launched providing (on a means-tested basis)vouchers that allowed uninsured persons and their dependents to have access toprimary and ambulatory care. However, eligibility and range of ambulatory provisionswere limited, inpatient care was not covered, and the scheme fell short of coveringneed. In 2016, new legislation lifted most barriers for uninsured citizens in accessingoutpatient and inpatient publicly provided care. Nevertheless, as the uninsured arebarred from contacting private providers contracted by EOPYY, inequity of accesspersists, especially in regions/localities with staff shortages and lack of diagnosticequipment in public health facilities.

39 Increased co-payments and fees as well as long waiting lists also function as rationingmeasures creating barriers to access. In certain prefectures, the quicker appointmentone can get for seeing a pathologist or a cardiologist in EOPYY could be in two or moreweeks, while in the national hospitals network it might take even longer (Petmesidou,2014: 23). Particularly long are waiting times for heart surgery: on average, two to fourmonths across the country, but in certain cases waiting may reach or surpass sixmonths (Boulountza, 2016). A ministerial decision issued in late 2016 made obligatory amore transparent use of priority medical criteria for waiting lists. Public hospitals havestarted complying with this measure, but it is too early to assess its effectiveness.Discontinuity in the procurement of vital medical supplies in ESY hospitals and PEDYhealth centers is another blockage mechanism.

40 Household expenditure data of the lowest income quintile show that, in the beginningof the crisis, average equivalized monthly health spending was a little over 10% of totalconsumption expenditure.15 It sharply dropped to about 7% in 2012, but increasedafterwards reaching again a ratio close to 10% in 2016 (with a slight decrease in 2017),even though total household expenditure persistently followed a downward trend from2009 onwards. With regard to the constitution of average monthly spending onhealthcare by households in the lowest income bracket (up to €750 monthly), a striking60% concerns pharmaceuticals (and medical devices), about 25% payments tophysicians, and the rest mostly inpatient care in private hospitals and clinics.

41 As healthcare demands are inelastic, significant cuts in public provision madenecessary even among poorer households to spend a growing part of their monthlyincome in order to cover healthcare needs. In the available literature, a threshold of 10to 15% (or over) of household monthly income (or consumption) spent on out-of-pockethealthcare payments is considered to be a “catastrophic” and “impoverishing” cost forhouseholds (see Xu et al., 2007). A case study conducted by Grigorakis et al. (2017) on thebasis of a sample of people covered by mandatory social insurance, who “werehospitalized at least once in private providers contracted by EOPYY”, highlights thehigh risk of “catastrophic health costs”. About a third of their respondents declaredhaving incurred a cost amounting to over 30% of their monthly income for health


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treatment (for the poverty impact of out-of-pocket payments see also Petmesidou et al.,2015: 253-268; Chantzaras and Yfantopoulos, 2018). Other case studies (see Tsiligiani etal., 2013 and 2014; Petmesidou et al., 2015: 295-342) also show that a substantial numberof people discontinue medication or lower their doses, as they cannot afford the cost,with perilous effects on their health though.

42 The geographical distribution of health facilities and personnel is a major dimension ofunequal access. Among EU countries, Greece exhibits a high ratio of practicingphysicians per 1,000 population (6.3, almost double the ratio EU28, in 2015), the vastmajority of whom are specialists. There are very few general practitioners, andshortage of nursing staff is a persistently serious problem, as indicated earlier. FigureIII shows the high concentration of health personnel in the two regions with the largesturban centers (Attica and Central Macedonia), as well as in two regions with well-established medical schools (Epirus and Kriti). It also depicts the prevalence ofdisability (and chronic diseases) by region (latest available data from an ad hoc study ofdisability carried out by ELSTAT in the early 2000s). Strikingly, the regions with thehighest rates in the prevalence of disability score lowest in terms of health personnelper hundred thousand inhabitants. Inequalities in the spatial distribution of healthfacilities are compounded by the problem of physicians’ brain-drain since the eruptionof the crisis (see Ifanti et al., 2014). According to the most recent available data, untilmid-2018 about 12,700 physicians (mostly specialists) left the country.16 FIGURE III – Regional Distribution of Health Personnel (2016) and Prevalence of Disability

Source: Eurostat data on health personnel by region and ELSTAT ad hoc study on disability (2002).Accessed on 20.11.2018, at https://ec.europa.eu/eurostat/data/database and http://www.statistics.gr/en/statistics/-/publication/SJO12/- respectively.

43 Barriers to accessing public health services in a time of crisis and inability to getmedical treatment in the private sector (because this is unaffordable for people ineconomic hardship) seriously increase unmet need for medical care. This is reflected inthe increasing use of free access clinics run by Non-Governmental Organizations –NGOs (e.g. Médecins du Monde). Until the late 2000s, people turning to NGOs weremostly immigrants. Only about 4% of Greeks sought “street medical care”. Yet, amidstthe crisis, estimates indicate that about a third of the Greek population turn to such


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http://www.statistics.gr/en/statistics/-/publication/SJO12/-




clinics or seek support for covering their healthcare bills (Petmesidou, 2014: 24; see alsoPetmesidou et al., 2015: 269-293; Adam and Teloni, 2015).

44 In the lowest income quintile unmet needs for medical examination have steadilyincreased from 2008 onwards (Figure IV). In 2017 close to a fifth of this income groupdeclared unmet needs. A significant increase characterized also middle-income groups(3rd income quintile). The respective rate for this income group equaled 12% in 2014,and slightly declined to 10% in 2017.17 Compared to the other three South Europeancountries (and to the EU28 average) unmet needs have been most prevalent in Greeceuntil recently. It is noteworthy also that, in the last few years, the intensification ofrefugee (and immigrant) flows in the country (mainly from the Middle East and Africa)further ratcheted up the pressure on public and voluntary health services. FIGURE IV – Self-reported Unmet Needs for Medical Examination (“too expensive, too far to travel orlong waiting list”)

Source: Eurostat data accessed on 10.11.2018, at http://ec.europa.eu/eurostat/data/database.

45 Although life expectancy at birth steadily increased over the last decades (81.5 years in2016, EU28 average 81.0 years), healthy life years at birth have been falling since 2007.Accelerating demographic ageing is a significant factor affecting this decline. Yet, atthe same time, there is evidence that austerity measures have significantly impactedupon the decrement in the populations’ health. According to the Global Burden ofDisease Study (2016: e404), “from 2010 to 2016, Greece was faced with a five-timesgreater rate of annual all-cause mortality increase and a more modest increase in non-fatal health loss compared with pre-austerity”. Specifically, we observe “a rise incommunicable, maternal, neonatal, and nutritional diseases since 2010” (ibidem; seealso Laliotis et al., 2016). Undoubtedly, it is rather difficult to disaggregate potentialroot cause factors of these outcomes (i.e. demographic profile, long-standing systemspecific characteristics, and the effects of austerity measures). Nevertheless, the factthat the worsening of public health takes place in tandem with a sharp reduction inpublic health spending and provision, makes it highly likely for the latter to haveplayed a major role in the deterioration of the population’s health conditions.

5. Conclusion

46 For a long-time health insurance and healthcare in Greece followed a splinteredpattern. In the early 1980s, on a highly fragmented health insurance system, a layer ofuniversalist healthcare was introduced. However, inequalities in the scope andcoverage among socio-occupational groups persisted, and the path breaking reform of


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http://ec.europa.eu/eurostat/data/database

the introduction of ESY hardly managed to become a driver of wholesale changetowards a fully developed national health system. Instead a “disjointed” configurationprevailed. This combined limited application of the principle of universal access withfragmented and unequal health insurance, in tandem with rapidly rising private, out-of-pocket payments. The statist-clientelist mode of socio-political integration thatcharacterized the country for many decades accounts for the consolidation of strong“veto” points resisting change. Subsequent reform attempts in the decades of the 1990sand the 2000s made little progress in tackling inherent system inequities andfinancing/organizational deficiencies.

47 The crisis provided a window of opportunity for promoting system integration, asenvisaged by the 1981 reform, yet under conditions of sharply declining publicspending and a leaner basket of provisions. A number of factors have facilitated reform.Fiscal surveillance by and increasing influence of supranational actors shifted decision-making upwards to the international lenders and the national executive branch, whiletraditional veto players, such as major trade unions and privileged health insurancefunds, were sidelined. At the same time convergent policy options among EU countriesguided reform towards: a) strict cost-containment and control measures shifting thecost to patients, and b) a two-pronged approach to governance consolidating serviceproviders but also decentralizing administration and management.

48 Undoubtedly, reforms increased system rationalization but blunt ceilings set by thebailout package drastically compressed the scope, quantity and quality of services.Seemingly, unification and standardization of health insurance aimed to tackleinequalities in coverage and access. But shrinking public provision runs counter to this.Unmet need for medical care greatly increased among lower-income groups (with anoticeable rise also among middle-income groups) and inequalities in terms ofaccessibility to and affordability of services deepened. Mandatory, state-regulatedcomplementary insurance through the market is absent and the risk of catastrophicout-of-pocket payments appears to be high, particularly so, as “reforms increasinglyco-opted universal public healthcare into private operators” (Petmesidou,forthcoming). Greece’s post-bailout commitments stipulating strict fiscal targets forthe years ahead, in order for the country to service its huge public debt, leave littleroom for any policy options, in the near future, which could reverse course and harnessthe potential of reform for enlarging the scope and improving quality of universalhealthcare.

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Xu, Ke; Evans, David B.; Carrin, Guido; Aguilar-Rivera, Ana Mylena; Musgrove, Philip; Evans,Timothy (2007), “Protecting Households from Catastrophic Health Spending”, Health Affairs, 26(4),972-983.

Zavras, Dimitris; Zavras, Athanasios I.; Kyriopoulos, Ilias-Ioannis; Kyriopoulos, John (2016),“Economic Crisis, Austerity and Unmet Healthcare Needs: The Case of Greece”, BMC HealthServices Research, 16(309), 1-7. Accessed on 15.11.2018, at https://bmchealthservres.biomedcentral.com/track/pdf/10.1186/s12913-016-1557-5.

NOTES1. This is a dismal performance compared to the other South European countries, which werebadly hit by the crisis too. In Portugal GDP (in real terms) reached its 2008 level in 2018, and inSpain it even surpassed its pre-crisis level (Romei, 2018).2. This indeed is “no true exit”, and “Greece’s parliament will have limited economic decision-making authority for years, or perhaps decades” (Mody, 2018).3. For a detailed analysis of the political and policy dynamics in Greece, at various stages of theevolution of the healthcare system since the restoration of democracy in the mid-1970s, seePetmesidou (forthcoming).4. In 2009, outpatient pharmaceutical expenditure amounted to roughly about 40% of total publichealth spending.5. According to the latest data by the Hellenic Statistical Authority (ELSTAT), in 2014, about 50%of the population suffered from a chronic disease. Accessed on 20.08.2018, at http://www.statistics.gr/en/statistics/-/publication/SHE22/-. 6. OECD health database. Accessed on 15.09.2018, at https://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT. 7. As Petmesidou and Guillén stated (2008: 115): “in 2006 health care expenditure (includinghealth care services and benefits) per head of the insured in the social fund for the self-employed(OAEE [the Social Insurance Fund for Self-employed Workers], excluding the professions)amounted to 344 euros. The corresponding rates for IKA, OGA (Agricultural InsuranceOrganization) and some of the ‘noble funds’ for public utility employees, like those intelecommunications and electricity, were 635, 648, 1,040 and 980 euros respectively”.8. A tiny number of health insurance funds did not join EOPYY (and EFKA). These include thehealth insurance funds of the Bank of Greece and the National Bank of Greece. 9. Recent legislation (Government Gazette 148/A/9-10-2017, accessed on 30.05.2018, at https://www.e-nomothesia.gr/kat-ygeia/proedriko-diatagma-121-2017-fek-148a-9-10-2017.html) setslimits to EOPYY’s status as an independent organization, through the establishment of a specialdepartment in the Ministry of Health, accountable directly to the Minister of Health andresponsible for overseeing a wide spectrum of decisions concerning EOPYY’s budget, the terms


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https://bmchealthservres.biomedcentral.com/track/pdf/10.1186/s12913-016-1557-5








https://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT




https://www.e-nomothesia.gr/kat-ygeia/proedriko-diatagma-121-2017-fek-148a-9-10-2017.html




and conditions under which private practitioners, diagnostic laboratories and private clinics arecontracted, and other activities.10. A clawback system requires pharmaceutical companies, private diagnostic centers andclinics, if expenditure exceeds the public health budget, to repay to EOPYY the excess. In 2018,the clawback by pharmaceutical companies reached €560 million, which is about 20% higher thanin 2017.11. Accessed on 15.10.2018, at https://www.taxheaven.gr/laws/circular/view/id/29287. 12. The income thresholds for exemption or lower rates of co-payments are set at €2400 and€3600 per year, respectively, for a single person (they increase by €600 for each dependent).13. In late 2018, only about 100 TOMYs (from a planned total of 240 units) started operating.14. Data from a research carried out by the Panhellenic Federation of Public Hospital Employees(POEDHN). Accessed on 05.10.2018, at https://www.poedhn.gr/deltia-typoy/item/2939-megali-erevna-tis-poedin-gia-tis-monades-entatikis-therapeias-se-74-nosokomeia. 15. ELSTAT data accessed on 15.10.2018, at http://www.statistics.gr/el/statistics/-/publication/SFA05/-.16. Data obtained from the Athens Medical Association.17. A study by Zavras et al. (2016: 5), referring to the early years of the crisis, found that, for thetotal population, “the odds of unmet needs due to financial reasons were 44% higher in 2011 ascompared with 2006”.

ABSTRACTSThis paper critically examines the health reform trajectory in Greece in the last decade. The firstpart provides an overview of the Greek healthcare system shortly before the crisis, with anemphasis on the incomplete development of a national health system beset by inequalities incoverage and funding. At the backdrop of the crippling debt-crisis that engulfed the country inthe late 2000s, the second part of the study tracks the major healthcare reforms under thesuccessive bailout packages. These are examined from the point of view of whether they cansecure the public system’s long-term viability and promote equity, or if they contribute to itswithering away instead. The third part of the article looks at the impact of the austerity-drivenreforms on inequalities in healthcare, highlighting some major findings regarding healthoutcomes.

Este artigo analisa criticamente a trajetória da reforma da saúde na Grécia na última década. Aprimeira parte apresenta uma visão geral do sistema de saúde grego em vésperas da crise, comênfase no desenvolvimento incompleto de um sistema nacional de saúde marcado pordesigualdades na cobertura e no financiamento. No contexto da debilitante crise deendividamento em que o país mergulhou, no final da década de 2000, a segunda parte do estudoacompanha as principais reformas dos serviços de saúde sob os sucessivos programas de resgate.Estes são examinados da perspetiva da sua eventual capacidade de garantia de viabilidade dosistema público a longo prazo, questionando ainda se promovem a equidade, ou se, em vez disso,contribuem para o seu desaparecimento. Na terceira parte do artigo, analisa-se o impacto dasreformas orientadas pela austeridade sobre as desigualdades nos cuidados de saúde e destaca-sealgumas das principais conclusões sobre os resultados em matéria de saúde.


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https://www.taxheaven.gr/laws/circular/view/id/29287

https://www.taxheaven.gr/laws/circular/view/id/29287

https://www.poedhn.gr/deltia-typoy/item/2939-megali-erevna-tis-poedin-gia-tis-monades-entatikis-therapeias-se-74-nosokomeia




http://www.statistics.gr/el/statistics/-/publication/SFA05/-




INDEX

Keywords: austerity, health funds, inequalities in healthcare, national health system, out-of-pocket paymentsPalavras-chave: austeridade, desigualdades nos cuidados de saúde, fundos de saúde,pagamentos do próprio bolso, sistema nacional de saúde

AUTHOR

MARIA PETMESIDOU

Emeritus Professor of Social Policy, Department of Social Administration and Political Science,Democritus University of ThraceP. Tsaldari 1, Komotini 69100, [email protected]


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The Impact of Austerity on thePortuguese National Health Service,Citizens’ Well-Being, and HealthInequalitiesO impacto da austeridade no Serviço Nacional de Saúde português, o bem-estardos cidadãos e as desigualdades na saúde

Pedro Hespanha

EDITOR'S NOTE


1. Welfare State, Crisis and Reforms in Portugal

1 In the last 15 years, social protection systems have been undermined in many countriesdue to the convergence of neoliberal ideas and the increasing financial and politicalrestrictions resulting from the state’s financial crisis originated in the second half ofthe 1970s, deepened during the 1990s, and turned acute as from 2008 – initially onlyfinancial and soon after economic, social and political crises. Neoliberalization, whichimplies public provision remarketing, reversion of policies’ universalism, and sharedgovernance of social protection, has been putting at risk the fundaments of bothwelfare state and welfare society.

2 Neoliberal trend reforms did not follow the same path all over the world (Jessop, 2013).Most European countries did not experience regime changes, but only adjustments intheir policies to safeguard central achievements of the welfare state. Nevertheless,


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there is the risk that these adjustments accumulate until the point of creating adefinitely neoliberal institutional framework of social welfare.

3 The emerging hypothesis regarding the nature of neoliberalization of the more radicalstructural adjustment processes, such as those occurring in Southern Europeancountries like Portugal, is that one may be observing not only a mere neoliberaladjustment, but rather a change of regime in the social protection system, as hasalready happened in other parts of the world that are subjected to structuraladjustment programs imposed by the International Monetary Fund (IMF) and theWorld Bank.

4 The historical alliance between market economy, welfare state, and democracy, whichfounded the modern nation-state project, appears to be breaking up at the present ageof global capitalism. Nevertheless, the welfare state still has strong public support andone cannot affirm that a totally ‘privatist’ and ‘individualistic’ ideology has penetratedthe values and expectations of Europeans. Actually, the state continues to be an arenaof tensions between the ideas of social services privatization and the ideas that defendthe public welfare provision for all citizens (Bourdieu, 1999, 2014; Wacquant, 2009).

5 If these characteristics are verifiable in all developed welfare states, they are even moreso in the Southern European welfare states that emerged in the context of theinternational crisis of the second half of the 1970s and where the social pacts enabledthe achievement of reforms in policies of social protection, employment, and incomeuntil the emergence of the 2008 economic and financial crisis. This crisis increasinglyreduced the margin of flexibility of governments that were strongly subjected to thesupervision of international institutions, thus forced to limit social dialogue regardingtheir main characteristics: decision-making autonomy of players and valorization ofcontributions from each part to the negotiation (Begega and Balbona, 2015), and, later,the impositions of adjustment programs following the sovereign debt rescue.

6 Focusing on Portugal, I will start by mentioning the factors that triggered the financialcrisis and the problems that led Portugal to be submitted to a readjustment program.These factors consisted in the accumulation, during the first decade of the currentcentury, of high external debts concerning the state, the families, and the firms. Thegrowing demand for external financing of public debt and for banking investmentprovoked a strong interest rate increase in the financial markets along with a ratingdegradation of the Portuguese sovereign debt and bank solvency.

7 The adjustment program started in May 2011 and lasted until mid-2015. There are twoaspects to be highlighted in the Portuguese case for the assessment of the anti-crisispolicy: first, since 2009, before the subscription of the program, the government hadstarted a set of measures to combat the crisis – Stability and Growth Programs I, II andIII – basically consisting of public expenditure reduction; second, after the right-wingcoalition government (2011), which had the responsibility to implement the adjustmentprogram negotiated with the Troika.1 Using the opportunity to impose its own agenda,clearly of neoliberal profile, this government moved further than the settled goals byreinforcing austerity measures.

8 The Memorandum of Understanding (MoU) subscribed by the Portuguese governmentcomprised a set of measures specifically directed to the health sector, along with othertransversal to different sectors aiming to reduce public expenditure (União Europeia et


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al., 2011). The analysis will focus on these measures and their negative and somehowunforeseen consequences.

9 The immediacy and urgency imposed by the bail-out program very much centered onthe control of public expenditure, fully conditioned the design and results of theadjustments and reforms. In a short period of time, a large number of measures wereimplemented along with a strict schedule monitored by the Troika every three months,which required from the government something that it couldn’t afford in thosecircumstances – time and negotiation ability (Sakellarides et al., 2014).2

2. The Blind Cuts and the Risk of ServicesDowngrading

10 The tight regime of austerity chosen to control public expenditure basically meant cutsin public expenditure. Using an accessible language that all people would accept, thegovernment formulated this objective in terms of “cutting off on the state’s fat”.However, distinguishing between ‘fat’ and ‘clean flesh’ revealed to be a difficult taskwhen immediate results were expected. In the beginning, “fats” were identified withcurrent expenses (not with personnel expenses), but soon it was clear that muchoutsourcing labor was also affected because in state accounting the “acquisition ofservices” is considered as a current expense.

11 Current expenses include activities that are instrumental to the services’ operation andtherefore necessary for their achievement – such as expenses with transportation and‘other specialized services’ (reduced by 25%), ‘purchase of services’ (reduced by 40%),‘payment of overtime, subsidies for night shifts, communications, legal services andtechnical assistance’ (reduced by 20%) and, very significant due to its high expression,expenses with outsourcing, i.e., staff with no employment relationship with the state,which from the viewpoint of public accounting was financed from the same budget asxerox copies. The drastic reduction of outsourced staff led to a ‘massive dismissal’ ofworkers or, in some services, the paralysis of work (Hespanha et al., 2014: 210).

12 The economic crisis impacted directly in health expenditure. Between 2010 and 2013the Gross domestic product (GDP) was reduced by 5.4% and the total health expenditureby 12.4% (INE, 2016). When we analyze public expenses in health since 2010 the twomost striking findings are the reduction of personnel expenses (between 2010 and 2012they were reduced by 27%) and the reduction of capital expenses (between 2010 and2014 they were reduced by 81%) (Table 1).3

Government expenditure on health fell more than in other public sectors, as theshare of health to general government spending came down from 13.8% in 2009 to12.3% in 2015. The public share of health expenditure fell more rapidly since 2011and in 2017 accounts for 66% of total health financing, below the EU average of 79%.The share of out-of-pocket payments is the second largest source of revenue forhealth care spending (28%), well above the EU average (15%). Private VHI has beengrowing over the years, but still only accounts for 5% of health financing,converging with the EU average. (OECD and European Observatory, 2017: 6)


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TABLE I – Public Expenses in Health (Portugal, 2010-2017), in Million Euros

CGE*2010

CGE2011

CGE2012

CGE2013

CGE2014

CGE2015

CGE2016

CGE2017

Current expenses 9 389,0 8 731,1 9 740,6 8 826,0 8 457,1 9 229,7 9 557,5 9 813,7

Personnel expenses 1 253,7 1 121,1 913,6 1 005,1 1 010,1 3 556,2 3 762,6 3 970,4

Pers. exp. /Total exp. (%)

13.2 12,7 9,3 12,4 11,8 37,7 38,7 39,9

Purchase of goodsand services

8 036,6 7 533,1 8,767.0 7 749,2 7 365,2 5 563,5 5 695,9 5 755,4

Current transfers 81,5 70,9 45,7 242,1 56,8 69,9 62,3 58,5

Other currentexpenses

15,2 6,0 14,4 16,5 22,8 33,2 26,7 23,5

Capital expenses 134,2 125,7 97,5 51,0 24,3 192,5 159,2 145,5

Purchase of capitalgoods

94,0 99,9 78,3 21,6 20,4 163,4 116,6 110,6

Capital transfers 40,2 25,8 19,3 5,5 3,9 2,4 0,7 5,9

Total expenses 9 523,3 8 856,8 9 838,1 8 877,0 8 481,5 9 422,2 9 716,6 9 959,2

* CGE – Conta Geral do Estado, i.e. General State Account.Source: Direção-Geral do Orçamento, Conta Geral do Estado – 2010/2017, disponível em http://www.dgo.pt/politicaorcamental/Paginas/Conta-Geral-do-Estado.aspx?Ano=2018.

13 In the absence of a structured reform program based on a hierarchy of necessities, atlarge it prevailed a blind application of cuts on expenses, with no attention to theimpact that these cuts would produce in very sensitive areas of health care. Also, themeasures for efficiency improvement were implemented without taking into accountthe capacities of health administration to achieve them, which resulted in many ofthem not reaching the expected objectives (Sakellarides et al., 2014).

14 The great criticism to be made about the implementation of the MoU is that it did notactually lead to the implementation of any of the reforms that were necessary andexpected. During the four years under the Troika’s rule, the government limited itselfto presenting a draft for the state reform that was not even discussed (Governo dePortugal, 2013).

15 The announced reforms of hospital care and primary health care may serve as anexample of what should have been done and has not been. Representing 60% of theexpenses of the National Health Service – NHS (Serviço Nacional de Saúde, inPortuguese), public hospitals were considered the reforms’ priority target. Thereshould have been a reorganization of the national hospital network, which was accusedof suffering from significant inefficiencies, such as the duplication of services providedin certain areas, as urgencies, maternities, oncology, and transplant services. However,


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http://www.dgo.pt/politicaorcamental/Paginas/Conta-Geral-do-Estado.aspx?Ano=2018




a report of the Troika (EC, 2014) recognizes that, although a lot had been done, thereform of the hospital network was far from being achieved and identifies a number ofcauses for this: resistance in the reclassification of hospitals and reallocation or sharingof medical equipment, low staff mobility and centralization of decisions that should bemade at regional level. Regarding the latter, it is obvious that the strong resistance ofservices and the unpopularity of the reform is, above all, an effect of the absence ofparticipation of the institutions and their officials and professionals in the reformdesign and implementation processes. Moreover, the fact that professionals wereexperiencing an overload of work did not contribute to a favorable atmosphere. Thisoverload resulted from the dismissal of staff with no replacement or replaced by“insufficient quantity of young unexperienced physicians who, regardless of theirspecialty, must work 18 hours shifts at the emergency service, instead of the previous12 hours”, as denounced by the President of the Portuguese Medical Association (Silva,2015; translation by the author).

16 Similarly, the reinforcement of primary health care stipulated in the MoU was notimplemented, despite the recognition of its potential contribution to the cost-efficiencyof the hospital and emergency care. An important component of this type of care isprovided by general practitioners or family doctors of the NHS, which are at the risk ofincreasing the numbers of citizens without medical assistant if new professionals arenot recruited to substitute those who have retired. Despite some positive changes –such as the approval of the professional profile of the family nurse, the creation ofvacancies for general and family medicine internship, and the creation of some FamilyHealth Units (Unidade de Saúde Familiar, in Portuguese) –, there are hindrances in thedaily work of professionals of Primary Health Care, which greatly hamper their tasks –from a deficient information system to the lack of human resources or the fragility ofsome operational unities (OPSS, 2014: 109).

17 The Portuguese Medical Association also reports some difficulties in staff recruitment.First, the freezing of public examinations for entry of family doctors led, on the onehand, to the emigration of many unemployed young physicians and, on the other hand,to hiring physicians in retirement situation as an alternative and cheaper option.Second, the incentives to keep doctors in the interior of the country turned out to beunacceptable due to the small amount of the mobility incentive and to the imposedmobility restrictions (five years of a mandatory period). Together with other causes,this explains the maintenance of one million Portuguese inhabitants (one and a half inevery ten) without a family doctor, despite the availability of human resources in themarket and the increase in the number of patients per family doctor, making itimpossible to manage the lists of patients waiting for consultation (Silva, 2015).

3. The Staff Reduction Priority

18 Staff reduction in public services became a government obsession, despite theawareness that the blind reduction of the number of employees would have serioussocial consequences in the crisis context. These reductions were achieved, to a largeextent, at the expense of worsening working conditions.

19 The reduction of health professional wages, the loss of holidays and Christmassubsidies (two extra month salaries) in 2012, the non-payment of overtime, the freezingof career promotions, and the no offer of public examinations for the recruitment of


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physicians and nurses led to the emigration of many unemployed professionals,4 theanticipated retirement of professionals with long careers and a considerable number ofprofessionals moving to the private sector. In the case of physicians, there was severecriticism to the decision of not hiring young professionals, whose education lastedmany years and to a large extent was financed by public resources, thus representing aserious waste of resources.

20 This situation led to a strike of physicians in July 2012, when the Ministry of Health andthe unions negotiated an agreement that included revision of wages, reduction ofheavy overloads, hiring new professionals, opportunities for career progression,extending users’ lists of family doctors (from 1500 to 1900) and increased mobility ofdoctors within the NHS (Sakellarides et al., 2014).

21 In spite of this, the effects of the staff reduction policy on the quality of health careservices associated with other austerity policies are a matter of great concern. Thesame with increasing levels of burnout syndrome among health professionals,associated with the perception of poor working conditions and reduced professionalexperience (WHO et al., 2018: 18; Marques and Macedo, 2018).

22 There are many examples of services that are going through processes of degradationas a consequence of the austerity cuts and discipline (Paoletti and Carvalho, 2012;Eurofound, 2012; Oxfam, 2013; Hauban et al., 2012). In some cases, the aim of costsreductions is concealed under the argument of greater rationalization of services orcompliance with international standards, as in the cases of closing urgencies andmaternities, prescription of medicines in public hospitals, and ‘implicit rationalization’of public health services.5

23 The services quality degradation resulting from the reduction or freezing of human andmaterial resources’ expenses, is one of the greatest threats to the public health system.It undermines citizens’ confidence and increases their dissatisfaction. A report fromOECD reveals critical aspects in the operation of hospital services: e.g. high fatility rateswithin 30 days after admission for ischemic stroke cases – 10.5% against 8.5% in OECDmember countries average (OECD, 2015: 29). Portugal also presented the worstperformance regarding waiting time for surgeries and the rate of infections associatedwith care in hospitalization (approximately 11% of hospitalized patients in 2012, wellabove the average of 6% in the EU) (ibidem).

24 In the same direction, another report on Portugal concludes that “in comparativeterms, the universal healthcare system produces good results, although the expensescuts have undermined inclusiveness and quality” (SGI, 2015). Yet, a study carried out byan independent Swedish organization placed the Portuguese National Health Systemfour positions below the one occupied in 2009, mainly due to excessively long waitingtime, reduction on co-payment of medicines, difficulty in the access to innovativepharmaceutical products, and a huge stagnation of the system (Björnberg, 2016).

25 It is worthy to recall the remark made by Ramesh Mishra, a long time ago, regardingthe strategy of residualization of public services followed by Margaret Thatcher’sgovernment: “cost containment and the decline of quality of public services may beexpected to lead to more private alternatives especially in times of increasing privateprosperity. In other words, universality may be weakened by attrition rather than byassault” (Mishra, 1990: 37). Or, as stated by Boaventura de Sousa Santos in 2002:

many of these services that are currently “public services” have almost endlessbusiness potentialities. In order to make this happen without much social


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disturbance, it is necessary that the idea of public service is gradually demoralized.The most efficient strategy consists in starting from false generalizations, takingblind measures, and justifying them with populist arguments (against the“misspending of taxpayers’ money”). (Santos, 2002; translation by the author)

4. Governments’ Limited Room for Maneuver

26 This crisis increasingly reduced the room for maneuver of governments that werestrongly subjected to the supervision of international institutions, thus forced to limitsocial dialogue regarding their main characteristics: decision-making autonomy ofplayers and valorization of contributions from each part to the negotiation (Begega andBalbona, 2015), and, later, the impositions of adjustment programs following thesovereign debt rescue.

27 In order to better control the implementation of the MoU, the government was forcedto reverse the ongoing decentralization process of the public health system. Thiscentralist return, not being an expressed option, was manifested by means of a set ofmechanisms that limited the participation of organizations and public health servicesin policies’ decision-making and concentrated them at the top of the Ministry ofFinances (OPSS, 2014: 23).

28 One of these mechanisms is the “law of commitments”, in force since the beginning of2012 to “reduce the deficit of Public Administration” and restrain “expendituregrowth”. It institutes that those responsible for the accountancy in public services maynot assume commitments that exceed the available funds in the short-term. Theassumption of multiannual commitments, including new investment projects,reprogramming of old ones or hiring contracts, among others, must be subjected toprevious authorization of the Ministry of Finances (Assembleia da República, 2012).

29 The OPSS considers that this law had very negative effects, in particular, on themotivation and accountability of the heads of health services, already disturbed by theexcessive and unnecessary bureaucratization of the process of personnel hiring andpurchase of goods and services.

The short term bureaucratic barriers and the environment of uncertainty regardingthe availability of resources for health care services hinder strategic planning,multiannual contracting, and, ultimately, organizations’ sustainability […].Transforming regional and local structures in mere driving belts for decisions takencentrally removes the efficacy, critical mass, experience, and innovation capacity tofind adequate solutions. (OPSS, 2014: 34; translation by the author)

30 Other mechanisms promoted as well the centralist return, by centralizing therecruiting of staff for the public administration into an inter-ministerial commission(Comissao de Recrutamento e Selecao para a Administracao Publica, in Portuguese); bymaking more difficult the celebration or the renewal of job contracts by state-ownedenterprises; by grouping the Health Centers for management purposes in regionalentities (Agrupamentos de Centros de Saúde, in Portuguese); by concentrating thedissemination of information in a centralized department of the Ministry for Health(Direção-Geral da Saúde, in Portuguese); and by creating limitations and constraintsconcerning decision-making within organizations, both in the administrative publicsector and the state-owned enterprises (OPSS, 2014).

31 In an inverse movement to that of centralizing decision-making, the governmententrusts more and more the private sector, for-profit or non-profit, with the


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responsibility of managing health units under the argument of public expensesreduction, without any clear evidence of its truth. For José Manuel Silva, the Presidentof the Portuguese Medical Association, there was a high increase in contractingservices with the private sector and the non-profit sector. At the same time, theMinistry of Health promoted the move of physicians and other health professionals tothe private sector. According to Silva (2015), the government has been promoting thedestruction of the small private medicine of proximity in order to favor the largehealth oligopolies, by imposing on them small rules that even the state does not complywith.

32 A particularly serious situation results from the fact that apparently positive measuresmeant to reduce expenditure and improve the well-being of users of the nationalhealth system are producing unexpected effects that have worsened the previoussituation. It is the case of the policy of reducing the price of drugs recommended by theTroika and thoroughly followed by the Portuguese government. This policy has severaladdressees: starting with the pharmaceutical industry and then the drugstore sector.

33 The government established several agreements with the pharmaceutical industry inorder to lower the prices of medicines and, in this way, to reduce public expenditureand to fix a new tax on the sales of pharmaceutical products in the modality ofwithholding tax. The price reduction was well-succeeded but generated an unexpectedproblem: some drugs became internationally competitive and the wholesalerspreferred to export them instead of supplying the national market as it was supposed.According to the Executive Director of Health Cluster Portugal, “these results havebeen produced by the ability of firms that, due to the prices being internally presseddown, searched for new markets” (Alves, 2016; translation by the author).

34 Regarding drugstores, it was verified that the reduction of the market margin ofmedicines also reduced their capacity to maintain stocks of the usual ones, resulting insupply shortage and, therefore, a decrease in patients’ access to them (OPSS, 2015;Vogler et al., 2011). According to OPSS, 1,756 drugstores had suspended their supply in2014, in at least one wholesaler (i.e., over 60% of the totality of drugstores in Portugaland with a growing tendency). In the same period, the global amount of the drugstores’litigious debt with wholesalers reached 303 million euros, to which is added the amountof 27 million euros for delayed payment, in pre-litigious phase (OPSS, 2015: 74). A studycarried out in 2012 concluded that approximately 88% of the drugstores reduced theminimum stock of most medicines, 86.5% reduced the average amount of purchasedpackages, and 92% reported almost daily difficulties to obtain medicines fromwholesalers (OPSS, 2013: 63).

35 The direct effect of the reduction of margins6 in combination with the indirect effect ofsuccessive reductions of prices of medicines,7 and the main remuneration source ofdrugstores (Martins and Queirós, 2015) resulted in a negative impact, especially todrugstores and wholesalers particularly affected by the double reduction in theirremuneration. Between 2011 and 2014, the market margin of medicines was reduced inapproximately 322.8 million euros, far above the 50 million euros established byTroika’s MoU. In this period, many drugstores were closed (Infarmed, 2015) and thesector registered an increase of 177% in the number of drugstores with insolvencyprocesses and 79.4% in the number of drugstores with pledges.


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5. Increasing Inequalities in the Access to NHS

36 In the European context, Portugal appears as one of the countries in which theinstitutionalization of social rights and the responses of the state with the adequatemeans for coherent social policy occurred later and were more problematic. This fact isrelated to historical circumstances that influenced the evolution of Portuguese societythroughout the 20th century, mainly in its second half. First, the persistence of adictatorial regime until the beginning of the 1970s, which delayed the modernization ofthe administrative apparatus and the establishment of citizenship rights. Second, aclear delay in the processes of industrialization, urbanization, and expansion of servicesector compared to what occurred in the northern European countries.

37 The so-called Estado Novo, ruled for nearly half a century by Salazar, adopted a modelof social regulation hostile to the development of consistent social policies. It stakeditself, rather, on a conservative ideology supported by the rural condition of large partof the population, which permitted the maintenance of social support based on familyand community solidarity and on weak expectations in relation to consumption andquality of life.

38 It was only after the establishment of the democratic regime in 1974 that the firstsystematic programs, aiming at the construction of a welfare state were developed.This was reflected in the growth of public expenses on welfare. However, this takeoffoccurred during an international economic crisis, exactly when the more developedwelfare states had begun to face the need of adopting more restrictive postures. As aconsequence, the expansionism felt since the change of regime was followed by a phaseof budget restraint after 1982, which prevented Portugal from approaching the modelof state producing welfare which characterized many other European countries.However, the frailties of the Portuguese “semi-welfare-state” (Santos, 1993) have beenpartially compensated for by the action of a civil society rich in community ties. This‘welfare society’ operates on a parallel with the systems of the state and of the market,and constitutes one of the singular elements of the welfare model dominant in thePortuguese society (Hespanha et al., 1997: 173).

39 Anyway, Portugal created its NHS in 1979, based on universalism, generality, and freeof charge (fully funded by taxes). Since its beginning the NHS faced many obstacles andlimitations: right-wing parties, the Portuguese Medical Association and the biggesthealth industry corporations joined together to constrain its development; theweakness of public resources for investment, including some areas of specializeddoctors, forced governments to make agreements with private health clinics,laboratories, and diagnostic units in order to ensure universalism. Later on, newhospitals were created under public-private partnerships and private hospitals werecommitted to assisting patients included in long waiting lists of NHS hospitals. Insteadof growing and gaining autonomy in the provision of services, as expected, thePortuguese NHS has become increasingly dependent on private provision(Carapinheiro, 2006; Campos, 2011, 2014; Carapinheiro et al., 2013).

40 The austerity policies imposed by the financial assistance program of the Troika sinceMay 2011 and embraced by the right-wing governments between June 2011 andNovember 2015 have greatly aggravated this picture as discussed previously.


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41 This austerity rule has not well defined outlines which may lead to quite differentinterpretations. To simplify, it can be said that it refers to a set of economic and socialpolicy options by which governments aim to halt or reduce public expenditure, andthat these options allow “altering the state’s redistributive policy and the expenditurerelated to the functioning of the economy and social reproduction” (Ferreira, 2014: 117;translation by the author).

42 The MoU signed in May 2011 by the Portuguese Government consisted of a shocktherapy for the recovering of the fiscal crisis that included a large array of measureswith a potential negative impact on social equity. First, to ensure a fiscal consolidationover the medium term by containing expenditure growth, reducing transfers from thestate to public bodies and other entities; second, to decrease the staff numbers ofcentral, regional and local administration, reducing the wages of civil servants,freezing new admissions as well as constraining their promotions; and to promoteflexibility, adaptability and mobility of human resources across the administration;third, to reduce social benefits, pensions and subsidies; fourth, to cut on expenses ofpublic bodies and state-owned enterprises and to reduce capital expenditure; fifth, toreduce corporate tax deductions and special regimes, to reduce the personal income taxbenefits and deductions; sixth, to increase VAT revenues and some special taxes;seventh, to reduce the degree of subsidization of public enterprises; eighth, toprivatize, total or partially, the biggest public enterprises. In the particular field ofhealth policies, the Memorandum includes the following measures: first, the strictcontrol of costs in health sector with substantial reduction in operational costs, inspending on overtime compensation, and in costs for patient transportation; second,the increase of overall NHS user charges or moderating fees (taxas moderadoras)8 inparallel to a stricter design of means-testing criteria for exempting taxes; third, thesubstantial cut in tax allowances for healthcare, including private insurance (by twothirds overall); fourth, the reduction of the budgetary cost of health-benefits schemesfor civil servants; fifth, the reduction of the reimbursement of medicines for patients.

43 The governmental coalition that ruled during the Troika period used austerity toenforce a project of state political reform of a neoliberal imprint, which under theargument that there is no alternative to austerity as a response to the crisis, restrainedexpenditure, privatized state-owned enterprises and used labour cost as an adjustmentvariable of the deficit. In result, political institutions became weak, inefficient andunqualified, citizens became dependent, poor, and deprived, and exceptional rightsthat do not respect the most basic principles of the rule of law and of democracy(Ferreira, 2014: 438).

44 Damages caused by austerity to the Portuguese economy and society manifested inmany ways. From the beginning, deep recession occurred with serious implications forthe future, not only due to investment halt and sovereign debt increase but mainlythrough social consequences: employment destruction and unemployment increase;precariousness, especially, of the younger segments of the economically activepopulation; large emigration flow of qualified workers; and worsening of poverty,social exclusion and income inequalities (Silva et al., 2013; Costa and Caldas, 2014: 119).A Caritas report on the impact of the crisis and austerity on people shows that the anti-crisis policies primarily based on austerity caused vulnerability on the weakermembers of society and therefore it could not be successful (Caritas Europa, 2013: 51).


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45 The social impact of austerity felt unequally on families and individuals. According to astudy published by the European Commission (Avram et al., 2013), among the nine EUcountries with larger budgetary deficits after the financial crisis at the end of the firsthalf of the 2000s and the subsequent economic recession (Estonia, Greece, Spain, Italy,Latvia, Lithuania, Portugal, Romania and United Kingdom), Portugal, Lithuania andEstonia are the only countries where austerity measures imposed heavier financialburden on the poor than on the rich. In the period from 2009 to June 2012, Portugalunderwent a regressive distribution, resulting mainly from the freezing of means-tested benefits,9 in a country that was already one of the most unequal in the EU. In asynthesis,

the financial crisis reduced the availability of public financial resources for healthservices coverage and investments. This has led to some reduction of services, thehigher financial burden to households and lower incomes of health services staff.The reductions have directly affected patterns of health and services utilization ofthe Portuguese population. (WHO et al., 2018: 32)

46 In order to analyze the consequences of crisis and austerity on inequalities, we mayconsider different dimensions: access to health care, increase in families’ out-of-pockethealth spending, reduction in public healthcare investment (Serapioni, 2017).

47 The Report of European Commission “Health inequalities in the EU” published in 2013(EC, 2013) distinguishes “health inequalities” (i.e. in life expectancy, in mortality), from“social inequalities” (i.e. in the conditions of daily life, based on power, money andresources) and outlines the different causes of inequalities and the policy responses. Itcompares data from 2009 to 2013 and concludes that the financial, economic and socialcrisis “is threatening to undermine existing policies, and may negatively affect healthinequalities” (ibidem: ix); and adverts to the fact that “inequalities in health cannot bereduced by the health sector alone – they require action on all the social determinantsof health” (ibidem). Thus, “most policies with explicit aims to reduce health inequalitiesfocus on ‘vulnerable groups’ such as immigrants, ethnic minorities, early schoolleavers, people from lower socio-economic groups or unemployed or homeless people”(ibidem).

48 We take these general traces common to the member states of the EU to inspire ouranalysis of the Portuguese case. The annual reports of the OPSS created in 2000 by anetwork of researchers and academic institutions are a good source of information foranalyzing the course of health inequalities in Portugal, but there are other recentstudies using other data and methodologies that also shed light on the same subject, aswe will see later.

49 The OPSS Report for 2015 (OPSS, 2015), the first year after the end of the externalintervention, used the access to health care as its central theme. Health careaccessibility is guaranteed to every citizen, “regardless of their economic condition”,by the Portuguese Republic Constitution (art. 64, no. 3, al. a). According to the OPSSreport for 2015 the crisis has interfered with access to health care, whether consideredthe dimensions associated with supply (human resources in health, access toemergency services, access to consultations, and availability of beds in hospitals) orthose associated with demand (socioeconomic conditions of citizens, out-of-pockethealth expenses, and unmet health needs).

50 The OPSS report for 2016 (OPSS, 2016) devotes a whole chapter to the theme of socialinequalities in health. It began by stating three reasons why health inequalities related


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to social and economic factors are a cause for concern: first, inequalities in health are amatter of social justice; second, they represent an economic cost to society; and third,they seem to have persisted, and even increased in some cases, over the last few years.The report concludes that the analysis carried out on social inequalities in health hasrevealed that health inequalities in Portugal have been consistently higher than thoseobserved in other European countries in the last decade and continue to be closelyassociated with socioeconomic factors (income, education, gender, age – children andelderly).10

51 Taking the level of education as an independent variable, it can be observed that,between 2005/2006 and 2014, people with lower levels of education has experienceddisadvantages regarding three health indicators (poor or very poor self-reportedhealth, the presence of at least one chronic disease, and the presence of functionallimitations). In particular, inequality is very high in reported ill-health, and in 2014uneducated people have a risk of being six times poorer than those with moreeducation (secondary education or more). For the same indicator, inequality seems tohave increased within 10 years, as for chronic disease. The increase in the risk of self-reported ill-health for uneducated people in 2008 and 2011 is understood as resultingfrom the onset of the crisis and the implementation of austerity measures, respectively.

52 The OPSS report for 2017, the first after the governmental change that reversedausterity policies since 2016, focused on equity in health care, assuming that equitymeans that care is distributed according to the needs and not to the ability to pay or tothe socioeconomic condition (OPSS, 2017: 73).

53 The assessment of equity in the access to health care has been measured by: i) theprobability of having unmet needs for four dimensions of care (medical appointmentsor treatments, dental care, purchase of prescribed drugs, and mental healthappointments or treatments); ii) the income category (in quintiles). There is a strongprobability of reporting unmet needs in all income categories, but this probability isquite unequally distributed in the cases of dental appointments (from 9% in the richestto 53% in the poorest) and mental health treatments (from 9% in the richest to 48% inthe poorest). Even for medical appointments or treatments in general, access barriersrange from 4% to 19%. Regarding waiting times, people in the highest income quintilehave a significantly lower probability of waiting for a consultation, as compared topeople in the lowest income (ibidem: 77).11

54 A recent academic study (Campos-Matos et al., 2017) followed the same objective usingEU-SILC database to analyze inequalities regarding three particular health limitations –daily activities due to health problems, self-reported health, and chronic conditions –in Portugal between 2004 and 2014. Demographic and socioeconomic variables – age,sex, income, education, occupation, activity, and savings – were used as explanatoryvariables. The proportion of individuals who had limitations was calculated for eachyear in the overall sample, within each income tercile, and stratified by age groups. Acomplex model of analysis allowed to observe that the proportion of individuals withlimitations (mostly in daily activities), was stable at around 30% until 2011, when itincreased to 43%, and then increased again in 2014 to 47% (ibidem: 2); however, healthinequalities seem to have decreased over the same period driven by an increase inlimitations in active people due to mechanisms such as migration trends (based on the‘healthy migrant effect’) and socio-economic groups’ different ability to adapt tochanging circumstances (ibidem: 5). Recognizing that these findings may be limited by


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the database design, the authors advocate “a more detailed exploration of thesechanges in the determinants of health, perhaps using longitudinal data, in order tocapture trajectories rather than compositional changes within socioeconomic groups”(ibidem).

6. Citizens’ Resistance Strategies Towards Crisis andAusterity

55 The manner in which insufficiency, downgrading or decreasing of services affectcitizens differs extensively according to a large array of variables, the same way asdealing with this situation differs. Systematic and comprehensive research on citizens’behavior is needed, which is hindered by the policy of public services opacity, on theone hand, and by the very unequal and irregular quality of data collection, on the otherhand.

56 It is important to stress that the effects of the reforms introduced in various domains ofthe health system should have been previously evaluated not only regarding theirbenefits for public management but also the disadvantages that they could bring tousers, as has already been mentioned.

57 For those citizens who saw the reduction of income and social support to which theyhad access, and also the aggravation of their living expenses, a common attitude is thereduction of health care demand such as consultations, exams, medicines, etc. Officialdata confirm the decrease of the number of consultations since 2011 and particularlythe high absenteeism to mental health consultations because patients cannot afford topay for transport costs (OPSS, 2015: 140). Regarding the purchase of prescribedmedicines, there is evidence that many patients do not buy on a regular basismedicines associated to certain diseases: chronicle diseases, high blood pressure andhypercholesterolemia, depression, etc. (Sakellarides et al., 2014).

58 The reduction of the exemptions on moderating fees, the duplication of the amount ofthese fees,12 and the extension of the moderating fees to other services,13 along with theincrease of the delay to access healthcare due to the shortage of professionals, havefurther aggravated the situation, namely for those patients who cannot afford to usethe private sector. However, there is evidence that those who can afford it shift to theprivate sector, subscribe to private health insurance (already covering 20% of thepopulation in 2011), or press the public system to respond as expected. Some cases ofthis pressure were much publicized, as the reaction against the rationing of expensivemedicaments. In February 2015 a hepatitis C patient protested at Parliament, face toface with the Minister of Health, against the decision to prevent the access to aninnovative treatment (with a high cure rate) based on the high cost of the treatment. Asa result, the government was forced to liberate the access to that medication for allpatients in the same situation.

59 But there are other alternatives. Citizens are not always isolated in the resolution ofproblems generated from or aggravated by austerity policies. This crisis also raises theemergence of answers within civil society, as for example mutual aid for the care ofdependent persons, informal assistance to children, sharing of private transportationor housing, medication bank, etc. The origin of such responses is very diverse:spontaneous emergence in proximity contexts; insertion in a social and solidarity


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economy logic; philanthropic or social volunteering inspiration (Laville, 2005, 2011;Laville and Jané, 2009; Hespanha and Santos, 2016).

60 Therefore, it is important to identify where the responses originate from and learn thedifferent aspects that allow us to evaluate their efficacy: the way in which the answersarise; their more or less formal and organized condition; the individualistic,particularistic or solidarity philosophy that inspires them; the type of solidarity thatfeeds them – to make it simple: paternalistic or democratic, vertical or horizontal –; itssphere of action more or less enlarged and integrated; the consistency and durability ofthese answers; their innovative and transformative character; and the institutionalrecognition of the answers.

7. In Defense of the Public Health Services

61 Several years of a strict policy of austerity, lack of investment and neglect of workconditions of the health professionals discredited and weakened the services and mayhave produced a strong negative impact on the people affected by the cuts and theshortage of services. The degradation of quality in health services resulting from thereduction or freezing of wages and capital investment is one of the great threats to thePortuguese NHS. It undermines citizens’ confidence, increases their dissatisfaction14

and exacerbates the current inequalities in accessing health care. However, thedamages caused by this policy will take some time to repair and this cannot be achievedwithout significant investment in human resources and infrastructure. Since 2016, anew government essayed a policy of reversing the main austerity measures byrecovering the citizens’ lost income and giving priority to the reversal of salaries, socialbenefits, and exemptions. But it lacks a steady policy of investment in human resourcesand infrastructure. “Although most of the wage cuts introduced in 2012 are currentlybeing reversed, the payment to health care workers in the NHS, particularly physicians,is lower than in the private sector” (Simões et al., 2017). The promise to create 100 newFamily Health Units is already consummated and represents an important investmentin order to expand and improve the Primary Health Care network and allow theallocation of family doctors to approximately more 500 thousand people (XXI GovernoConstitucional, 2015: 97). An increase in hiring health professionals to compensate forstaff outflows caused by austerity and the reduction of the working week from 40 to 35hours, has been successfully accomplished. In contrast, the recovery of the pre-crisislevels of investment in hospitals has failed, despite the statement by the Minister ofHealth, Marta Temido, that hospitals of the NHS will benefit, in the next three years, of500 million euros of equipment investment (O Jornal Económico com Lusa, 2018).However, the real challenge to the government consists in making the neededinvestment with public funding15 and at the same time maintaining financialsustainability, through increasing efficiency in NHS health units (Simões et al., 2017:171).

62 The combined analysis of the evolution and impact of the austerity on social policieswith the way in which Portuguese society is suffering the impact of the crisis reveals ahuge lack of legitimacy of the austerity measures, regarding the values and legitimateexpectations of social welfare in a modern European society based on the principles ofpolitical and social citizenship. At the same time, these measures are contributing tothe loss of social capital, generating the risk of destroying the society’s fundaments.


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63 Whatever the circumstances are, it is important to sustain that the reform of NHScannot abandon the essential objectives to minimize inequalities, protect the morevulnerable persons, and improve the well-being of all citizens. There are still manyobstacles – possibly even more than in the past – for the improvement of publicservices, and one of them, very important, is the bureaucratic, authoritarian andclientelist nature of public administration, which the democratic political systemintended to transform, but was not able or did not want to. Lately one observes thereinforcement of these tendencies and the increasing opacity of the criteria of publicadministration management, thus hampering the access to information on theausterity impacts.

64 The NHS becomes essential in a context of crisis and the consequences of itsdegradation or suppression will be dramatic for the majority of the Portuguese citizens.Therefore, the defense of social welfare and the role of the state in health protection ismade, largely, through requesting the ability of health services to adjust to the newrealities, making good use of the responses that society has invented – such asproximity services, health in the community, informal care –, creating closer bondswith territories, and giving more attention to the needs of the community at eachmoment.

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Santos, Boaventura de Sousa (1993), “O Estado, as relações salariais e o bem-estar social na semi-periferia: o caso Português”, in Boaventura de Sousa Santos (ed.), Portugal: um retrato singular.Porto: Edições Afrontamento, 15-56.

Santos, Boaventura de Sousa (2002), “A ideia do serviço público”, Visão, 29th May. Accessed on30.10.2017, at http://saladeimprensa.ces.uc.pt/index.php?col=opiniao&id=1708.

Serapioni, Mauro (2017), “Economic Crisis and Inequalities in Health Systems in the Countries ofSouthern Europe”, Cadernos de Saúde Pública, 33(9). DOI: 10.1590/0102-311x00170116

SGI – Sustainable Governance Indicators (2015), “Portugal: Social Policies”. Accessed on30.10.2017, at http://www.sgi-network.org/2015/Portugal/Social_Policies.

Silva, José Manuel (2015), “O necessário e resumido balanço de quatro anos de Ministério daSaúde. Olhar o passado a pensar no futuro”, Revista da Ordem dos Médicos, 162, 5-11.


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Tribunal de Contas (2016), “Auditoria à execução do contrato de gestão do Hospital de Braga emparceria público-privada (PPP)”, Relatório n.º 24/2016 – 2.ª Secção, volume I. Lisboa: Tribunal deContas. Accessed on 10.09.2018, at https://www.tcontas.pt/pt/actos/rel_auditoria/2016/2s/rel024-2016-2s.pdf.

União Europeia; Fundo Monetário Internacional; Banco Central Europeu (2011), “Memorando deentendimento sobre as condicionalidades de política económica”. Lisboa: Ministério das Finanças.

Vogler, Sabine; Zimmermann, Nina; Leopold, Christine; Joncheere, Kees de (2011),“Pharmaceutical Policies in European Countries in Response to the Global Financial Crisis”, Southern Med Review, 4(2), 69-79.

Wacquant, Loïc (2009), Punishing the Poor: The Neoliberal Government of Social Insecurity. Durham:Duke University Press.

WHO – World Health Organization; República Portuguesa; European Observatory on HealthSystems and Policies (2018), Health System Review: Portugal. Phase 1 Final Report. Accessed on23.10.2018, at https://www.sns.gov.pt/wp-content/uploads/2018/04/PortugalReviewReport_Printers_03April2018-2.pdf.

XXI Governo Constitucional (2015), Programa do XXI Governo Constitucional 2015-2019. Accessed on07.11.2018, at https://www.portugal.gov.pt/ficheiros-geral/programa-do-governo-pdf.aspx.

NOTES1. A consortium of creditors constituted by the European Commission (EC), the European CentralBank (ECB) and the International Monetary Fund (IMF).2. For a better understanding of the sovereign debt crisis in Portugal and of the economicadjustment programs for the health sector imposed by the troika memorandum ofunderstanding, see Hespanha (2017).3. The data of the European Observatory on Health Systems and Policies are collected from theNational Budgets (Orçamento Geral do Estado, in Portuguese) and, therefore, the numbers are alittle higher (between +6,9% in 2012 and +2,5% in 2014). 4. It is estimated that, since 2009, 14,780 nurses have applied for emigration documents (Rita andSaramago, 2016). According to the President of the Medical Association, “hundreds of physiciansare emigrating every year and if we don’t do what is necessary to retain them it will be a greatloss, in terms of investment and scientific knowledge. We are exporting brains” (Observatório daEmigração, 2015; translation by the author). Furthermore, the dynamics of medical school


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https://www.tcontas.pt/pt/actos/rel_auditoria/2013/2s/audit-dgtc-rel018-2013-2s.pdf




http://www.tcontas.pt/pt/actos/rel_auditoria/2015/2s/audit-dgtc-rel019-2015-2s.PDF

http://www.tcontas.pt/pt/actos/rel_auditoria/2015/2s/audit-dgtc-rel019-2015-2s.PDF

https://www.tcontas.pt/pt/actos/rel_auditoria/2016/2s/rel024-2016-2s.pdf




https://www.sns.gov.pt/wp-content/uploads/2018/04/PortugalReviewReport_Printers_03April2018-2.pdf




https://www.portugal.gov.pt/ficheiros-geral/programa-do-governo-pdf.aspx

https://www.portugal.gov.pt/ficheiros-geral/programa-do-governo-pdf.aspx

graduates and the retirement of medical doctors are likely to generate a surplus that may not beabsorbed by the healthcare system until 2025 (Santana et al., 2014).5. A broad description of the signs of health services downgrading and progressive inaccessibilityto patients is available in the 2012 issue of Portuguese Observatory of the Health Systems (OPSS,in the Portuguese acronym).6. Decreto-Lei no. 112/2011, from 29/11, altered by Decreto-Lei no. 19/2014, from 05/02.7. The reduction of expenses per capita with medicines was of 5.9% in 2010 and 2011 (OECD,2015).8. Before this increase, moderating fees represented 0.74% of the NHS total revenue in 2010 and0.95% in 2011. In 2012, they accounted for 1.7% and in 2015 about 2.0% (WHO, 2018: 27). 9. The estimates of the austerity weight on the distribution model largely depends on theanalytical choices and assumptions: for example, whether or not to include cuts on in equipment,such as wheelchairs, articulated beds, food; or the effects of increases on Value-Added Tax (VAT)on families. This explains the discrepancies in these estimates (Laparra and Pérez Eransus, 2012).Spain is considered the most regressive among the five countries – Germany, Denmark, Spain,France, and United Kingdom.10. Main statistical sources used: The National Health Surveys (Inquérito Nacional de Saúde, inPortuguese) of 2005/2006 and 2014, the European Health, Aging and Retirement Survey (SHARE),and the EU Statistics on Income and Living Conditions (SILC).11. According to the Eurofound European Quality of Life Survey 2016 a delay in getting anappointment was reported as being ‘very difficult’ for 18% of respondents in 2016 in Portugal(Eurofound, 2017: 53). 12. This revision of the moderating fees regime raised several questions: a) inequity of theduplication of fees amount when a severe economic and social crisis was underway; b) anassistance logic and a stigmatization risk behind the limitation of access to moderating feesexemption only to those who prove not to have the required means; c) very high costs toimplement a control system for requests of fees exemption; d) reduced impact on health budgetfrom the rise of moderating fees; and e) the fact that the moderating fees fall on the delivery ofhealth services not chosen by users, but rather those prescribed by the doctors (Sakellarides etal., 2014).13. Services of nursing, vaccination not included in the national vaccination plan, radiologicexams, and therapeutics in the scope of urgency services.14. More than half of the respondents in a study on the satisfaction of the users of thePortuguese health system feel that public health services need major changes/adjustments(38.2%) or to be completely restructured (15%) (DGS, 2015).15. There is a staunch debate in Portugal about the public nature of the NHS, since the creation,in 2002, of public-private partnerships (PPPs) for the management of public hospitals. Recentreports from the Court of Auditors have concluded, first, that “there is no evidence to confirmthat the option for the PPP model generates added value compared to the traditional contractingmodel” (Tribunal de Contas, 2013: 16 and 2015: 8; translation by the author), and second, that“the production of hospital care agreed annually between the state and the private partner hasnot been subordinated to the needs of the population's health services, leading to increased listsand waiting times for consultations and surgeries” (Tribunal de Contas, 2016: 3; translation bythe author). This debate rebound recently in the Parliament when the Government submitted aproject to change the Health Framework Law of 1990 (Lei de Bases da Saúde, in Portuguese),which established the principle of parity between the public and the private sectors of healthcare and promoted the development of the private health sector in competition with the publicsector (Base 2, al. f).


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ABSTRACTSThis article discusses the main lines of the anti-crisis policy in Portugal, its consequences on thecitizens’ well-being and health inequalities and the impasses in health reforms planned both toensure the financial sustainability of the health system and to improve equity. Different studiesreveal that health inequalities in Portugal have been consistently higher than those observed inother European countries in the last decade and continue to be closely associated withgeography, income, and health literacy. In the absence of a well-structured reform program, theblind cuts on expenses prevailed, showing no consideration to their impact in very sensitiveareas of medical care. The manner in which slowness, insufficiency or downgrading of servicesaffects citizens differs according to their social condition and the way they deal with thesituation. The article is illustrated with examples of how citizens, families, and civil societyorganizations have sought to circumvent the lack of response from public health services.

Este artigo discute as principais linhas da política anti-crise em Portugal, as suas consequênciassobre o bem-estar dos cidadãos e sobre as desigualdades em saúde, bem como os impasses nasreformas em saúde planeadas para garantir a sustentabilidade financeira do sistema de saúde emelhorar a sua equidade. Diferentes estudos revelam que as desigualdades na saúde em Portugaltêm sido consistentemente mais altas do que as observadas em outros países europeus na últimadécada e continuam intimamente associadas à geografia, ao rendimento e à literacia em saúde.Na ausência de um programa de reforma bem estruturado, prevaleceram os cortes cegos nasdespesas públicas, sem levar em consideração o impacto que esses cortes produziriam em áreasmuito sensíveis dos cuidados médicos. A maneira pela qual a lentidão, a insuficiência ou adesqualificação dos serviços afeta os cidadãos difere de acordo com a respetiva condição social ecom a maneira como lidam com a situação. O artigo é ilustrado com exemplos de como cidadãos,famílias e organizações da sociedade civil tentaram contornar a falta de respostas dos serviçospúblicos de saúde.

INDEX

Keywords: austerity, crisis, health inequalities, health reforms, National Health SystemPalavras-chave: austeridade, crise, desigualdade em saúde, reformas na saúde, Serviço Nacionalde Saúde

AUTHOR

PEDRO HESPANHA

Faculdade de Economia da Universidade de Coimbra | Centro de Estudos Sociais da Universidadede CoimbraAvenida Dr. Dias da Silva 165, 3004-512 Coimbra, [email protected]


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The Lasting Effects of a “RelentlessCrisis”: The Great Recession andHealth Inequalities in SpainOs efeitos permanentes de uma “crise infindável”: a Grande Recessão e asdesigualdades na saúde em Espanha

Juan Antonio Córdoba-Doña and Antonio Escolar-Pujolar

EDITOR'S NOTE

Edited by Ricardo CabritaReceived on 08.01.2019Accepted for publication on 23.06.2019

1 Evidence on how the previous and current crises have affected the well-being of thepopulation is still fragmented and uncertain, particularly with respect to healthinequalities. Alongside this, in recent years the focus has been more on studying theimpacts of post-crisis cutbacks on health, especially in Europe (Toffolutti and Suhrcke,2019). Several mechanisms have been suggested to explain the effects of the globalfinancial crisis and associated structural reforms on health outcomes. Kentikelenisproposed three pathways by which austerity measures could affect health: (i) policiesdirectly target health systems; (ii) policies have an indirect effect on health systems;(iii) policies affect the social determinants of health (Kentikelenis, 2017). Morespecifically, it has been claimed that the most obvious effects of the austerity-drivenwelfare reforms (that have taken place) since 2008 have been channeled through socialwelfare cuts and labor market policies (Ruckert and Labonté, 2017).

2 Spain is generally regarded as one of the European countries most affected by the GreatRecession that followed the global financial crisis of 2008 (Ministerio de Sanidad,Consumo y Bienestar Social, 2018a). According to the foregoing considerations, it isworth highlighting the important role played not only by the cyclical change in


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unemployment rates but also by the high structural unemployment in Spain that haspersisted for several decades. These aspects have been thoroughly evaluated inmultiple studies in recent literature. However, much less attention has been paid todate to the role of the policies implemented that affect the performance of the healthsystem. Besides this, any attempt to gain a better understanding of the consequences ofthe crisis and subsequent restrictive policies for the welfare state, especially the healthsector, should include the history of the Spanish National Health System (SNHS) fromthe middle of the last century onwards. To date, analyses of the impacts of the GreatRecession on health have been mostly based on very recent historical frameworks, withscant evaluation of the relations between political power and health policies. Adescription, even in a very summarized form, of the historical roots of our nationalhealth system, makes the changes that have taken place during our short democratichistory more understandable as do those that have developed subsequently during theGreat Recession, under the auspices of the adjustment policies imposed by theEuropean Union (EU) together with Spanish governments (budgetary cuts, personnelreductions and privatizations, among others).

3 This study aims to contribute to this area of research by evaluating the impacts of theeconomic recession starting in 2008 on health and health inequalities, with emphasison the historical process and previous economic and political context, and does notlimit its analysis to the consequences of the steep fall in GDP and the sharp increase inunemployment and precariousness rates.

4 We first present a historical overview, ranging from the period of the Francodictatorship, through the democratic era, to the period of the Great Recession, wherewe focus especially on citizens’ responses to austerity measures within the healthsystem – highlighting the “white tides” movement – which, according to ourhypothesis, may have been a buffer against the negative consequences of austeritypolicies. In the second part of this study, we provide a selective review of the mainscientific findings on the effects of the Great Recession in Spain, covering most of theoriginal papers published in international health-related journals in English andSpanish up to November 2018, as well as selected documents drawn from the referencelists of relevant articles. Our review focuses particularly on the effects of the GreatRecession on mental health outcomes and on inequalities in health and healthcareutilization.

Part 1. Historical Background

The Legacy of Francoism (1939‑1975)

5 From the end of the Civil War in 1939 until the first democratic elections in 1977 theFranco dictatorship’s approach to public health was based on a division between healthcare services, which were under the control of Falangist ministers in the Ministry ofLabor, and public health services, which were the responsibility of the Ministry of theInterior, under the supervision of Catholic military officials (Rodríguez-Ocaña andMartínez-Navarro, 2008). As early as 1967, in a report on the organization of the healthservices in Spain, Dr. Fraser Brockington, a World Health Organization (WHO)consultant, criticized the Franco administration for failing to establish a Ministry of


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Health and retaining a system in which the various aspects of health services weredispersed across different ministries (Brockington, 2018 [1967]).

6 To a large extent, Franco’s government limited its efforts to maintaining the healthsystem designed in the Second Republic (Rodríguez-Ocaña, 2008). In the middle of thecivil war, the Republican government tried to establish something resembling anational health service, as specified in a document of the Popular Front “[...] the Statewill take care that each man or woman of the people remains healthy and is dulytreated if he or she falls ill” (Huertas, 2000: 41).1

7 For almost 40 years the Franco regime maintained a very centralized, paternalistichealth system that was extremely fragmented (Pons-Pons and Vilar-Rodríguez, 2011;Aguilar, 2010). Brockington’s (2018 [1967]: 10) report stated that “the health of thecommunity constitutes a unitary domain that suffers if it is broken down into differentand independent sectors; the diversity of efforts and the lack of integration of servicesare harmful”. It also stressed that “the principles of social and preventive medicine areconspicuous by their absence” (ibidem: 3), a problem that remains, at least to someextent, to this day. It was not until the introduction of democracy that health care wasrecognized constitutionally as a right of citizenship. Changes During the First Period of Democracy (1977‑1986) andConsolidation of the National Health System (1987‑1992)

8 When democracy was introduced, Spain’s first democratic government inherited ahealth system that had serious deficiencies in outpatient health care and out-of-datepublic health services and had ignored the country’s changing epidemiological profile,which had come to be dominated by non-communicable diseases. There were alsoserious deficiencies in health information systems and in the training of medical andpublic health professionals.

9 Internationally the 1970s were marked by a major global economic crisis, and risinghealth care costs meant that the need to reform Western health systems entered thescientific and institutional agendas (Lorraine and Götze, 2011). The Laframboise-Lalonde Report had shown that biomedical interventions were only one of theinfluences on health, which was more strongly associated with social, environmentaland lifestyle factors (Lalonde, 1974). It followed that existing health policies should bereplaced by policies that prioritized prevention and health promotion and builtpeople’s capacity to manage their own health and well-being. In 1978, the Alma-AtaConference endorsed moves to challenge the then dominant hospital-centric model ofhealth care and reaffirmed the centrality of universal health care to improve the healthof the population, emphasizing that the main focus should be on primary care (WHO,1978).

10 The creation of Spain’s first Ministry of Health in 1977, two years after the death of thedictator Franco, did not lead to a substantial modification in the programs or territorialorganization of the previous health system. It was not until the Spanish SocialistWorkers Party (PSOE) entered government in 1982 that enough momentum wasgenerated to set in motion a whole series of legislative initiatives aimed at establishinga welfare state that would put Spain on the same level as other European countries. Theenactment of the General Health Law (Ley General de Sanidad, LGS) in 1986 stood outamongst these initiatives (Magro, 2016). The LGS was underpinned by three basic aims:


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to reorganize primary health care, to encourage community participation and toimplement inter-sector policies. Amongst the greatest achievements of these reformswere the universalization of health coverage (98.5% in 1995), the introduction of thespecialization in Family and Community Medicine, greater administrative integrationof the healthcare network and an improvement in the quality of care (Benach, 2018).

11 The devolution of health competencies to the 17 Autonomous Communities startedbefore the enactment of the LGS. This process enabled the first modernization of thestructure and services provided by health care units (hospitals and outpatient services)and was not completed until 2002. At present – in very general terms – the HealthDepartments of each region set their own annual budgets and purchase health careservices from Regional Health Services (SRSs), which are in charge of the managementof hospitals, clinics and primary care centers. Health Departments may also contractservices out to private providers, who generally play a minor role in overall provision,although this varies greatly between regions. The provision of care services is free atthe point of care, with the exception of drugs and some ancillary products (prostheses),for which co-payment up to a maximum is expected (VV. AA., 2018a).

12 Over the course of a decade (1982‑1992), an intensive program of reform wasimplemented, albeit unevenly across regions; this was accompanied by majorinvestments in infrastructure and human resources, especially in relation to theincorporation of family and community medicine specialists and nursing professionalsinto the new primary care centers (Rodríguez-Ocaña et al., 2008). In spite of theseefforts, the health system continued to be focused primarily on assistance, prioritizingexisting illness over the promotion of health; the biomedical continued to dominateand there was a certain disregard for the social determinants of health and communityaction in health (Benach, 2018). Although initially the objectives of the new primarycare centers (Health Centers) were formulated in accordance with the principles ofAlma-Ata and the Ottawa Charter, the rise of the neoliberal tide led to their progressivereplacement by objectives couched in terms of the management of care processes andbased on a vision of an internal market and the implementation of programs aimed atmodifying individual lifestyles. The Rising of the Neoliberal Tide: Counter-reforms of the HealthSystem (1990‑2018)

13 In 1990, only four years after the enactment of the LGS and with the EuropeanCommunity pressing Spain to reduce its public deficit, the PSOE government set up acommission of experts known as the “Abril Commission”. Its final report noted thatthere was a need to introduce private management of public health services, to extendprivate sector participation in publicly-funded care, to separate funding and provisionof services and to extend the co-payment scheme for medication to pensioners(Gobierno de España, 1991). Opposition to the Abril Report meant that the drive forprivatization was delayed for a few years, but it received further support after theapproval of Law 15/1997, which is still in force. This law enabled new forms ofmanagement of the SNHS (BOE, 1997). It made it legal for provision and management ofhealth and social-health services to be carried out by means of agreements or contractswith public or private persons or entities. Policies, based on this law, that werepromulgated during the period 1996‑2004 by governments led by the Popular Party


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(PP), fueled an increase in private management of publicly-funded services (FADSP,2017). In the regions where PP governments predominated, privatization initiativestook the form of public-private partnerships for the construction and management ofhospitals, outsourcing of healthcare activities (mainly surgery), diagnostic proceduresand complementary services (FADSP, 2017; Ponte-Mittelbrun, 2005). Although regionswith PSOE governments opted for policies that reflected a greater commitment to apublic health system, they passed laws incorporating some of the recommendations ofthe Abril Report.

14 However, the most serious attack on the public health model defined in the LGSoccurred in 2012, in the midst of the Great Recession, thanks to the enactment by thePP government of Royal Decree-Law 16/2012 (BOE, 2012). This decree was part of theneoliberal austerity policies promoted by the EU, which were designed to reduce publicspending and prioritize debt repayment. The decree linked the right to health care tothe condition of being insured, breaking the principle, which had until then prevailedin the SNHS, that the right to health care was conditional only on citizenship (Sánchez-Bayle, 2012). One of the consequences was the exclusion of illegal immigrants fromhealth care, with 873,000 health cards being withdrawn from foreign residents(Médicos del Mundo, 2013). The replacement rate for public sector retirements waslimited to 10%. Although not all the cuts that were implemented have been reversed,RD 16/2012 was partially revoked recently, through Royal Decree 07/2018, which statesamong its general provisions “[...] access to the National Health System underconditions of equity and universality is a fundamental right of every person” (BOE,2018).

15 Neoliberalism’s penetration of healthcare field and the neoliberal recipe for austerityin public spending have reached all areas of healthcare in Spain, affecting specialistservices the most and influencing the ideas of politicians and managers of public healthcare services (Navarro, 2012). This penetration stalled in 2011 when citizens mobilizedstrongly in defense of public health services. This mobilization was underpinned by thestrongly favorable opinion that the Spanish population has of the SNHS, despite theimpact of neoliberal austerity policies (Sánchez-Bayle and Fernández-Ruiz, 2018). The Great Recession and Its Collateral Effects on the Social HealthSystem. Social Inequality Spikes (2008‑2018)

16 The first manifestation of the Great Recession in Spain was the bursting of the realestate bubble, generated over the decade prior to the 2008 crisis by a very lax creditpolicy and, by extension, the breakdown of the speculative instruments created andused by US investment banks and their insurance companies (Weissman, 2009). Theincompetence of the regulatory bodies, mainly the Bank of Spain, allowed anunsustainable expansion of credit to families and companies in the real estate sector(Navarro, 2012; Ekaizer, 2018). The Spanish banks, especially the savings banks, whichtransferred speculative capital from Central European banks, were particularlyaffected. Eventually, the government decided to offer the banks a publicly-financedbailout which, although officially estimated at 122 billion euros by the Court ofAuditors, would rise to some 300 billion euros if other types of indirect aid were takeninto account (Ekaizer, 2018). Spain’s public debt which, at 35.5%, had been amongst thelowest in the EU in 2007 rose to 99.0% of GDP in 2016 (Delgado et al., 2018). The priority


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given to payment of this private debt, which had been converted into public debt,became a constitutional norm when the two big parties, PSOE and PP, agreed inSeptember 2011 on a rapid reform to the Constitution (BOE, 2011), making controllingthe deficit an absolute priority that took precedence over other economic measuresthat might mitigate the negative impact of the Great Recession.

17 The consequences of the reduction in social spending have been, and continue to be,dramatic. Unemployment increased from 8.6% in 2007 to 25.7% in 2012, when the youthunemployment rate was above 50%, representing the destruction of almost 4 millionjobs between 2007 and 2014. There has also been a deterioration in the quality ofemployment, with an increase in part-time hiring of 16-29 years old from 26% in 2007to 44% in 2016. Only 48% of the population affiliated to the social security system in2017 had full-time permanent contracts while the majority (52%) held temporary and/or part-time contracts. The poverty rate grew from 23.6% in 2008 to 26.6% in 2017, withfamilies with dependent children and single-parent families (mostly headed by women)having the highest relative poverty rates, at 24.1% and 40.6% respectively. The GreatRecession has made 4 million people extremely vulnerable and there has been a 40%rise in the number of people classed as severely excluded compared with 10 years ago(Cumbre Social Estatal, 2018). The Gini index rose from 31.9 in 2007 to 34.1 in 2017(Eurostat, 2017), making Spain one of the most economically unequal countries in theEU.

18 Neoliberal austerity measures led to a fall in public health expenditure as a percentageof total health expenditure, from 73.6% in 2009 to 70.8% in 2017 (OECD, 2018). Inabsolute terms, this represents a cut of 15‑21 billion euros and is reflected in the loss of9,600 jobs in public hospitals between 2010 and 2014. The cuts to primary care services,15.5% between 2009 and 2014, were five times as severe as the cuts to specialist services(Médico Crítico, 2016; Simó, 2016). As a consequence of the deterioration of publichealth services, private spending on health increased from 26.4% in 2008 to 29.2% in2017.

19 As the historian Josep Fontana pointed out,What Spanish citizens pay for today through cuts, unemployment and sacrifices arethe gigantic debts of financial institutions that committed their resources to high-risk investments in order to be in a position to distribute profits and commissionsto their executives and to political associates who first let them do it and thenaccepted that the state bail out the banks and savings banks, but not those ofthousands of families who have been evicted. (2013: 61)

Resistance to Austerity Policies in the Health Sector. The SocialPhenomenon of the White Tides

20 Throughout the different stages of democratic government in Spain, there have beencivil movements arguing in favor of the right to health as a common good that shouldnot be subject to the law of markets. One of the most notable groups campaigning insupport of the SNHS in the past 35 years is the Federation of Associations for theDefense of Public Health (FADSP) (Palomo, 2011). During the last two decades, FADSPwas the core group in the formation of multiple Platforms in Defense of the PublicHealth System throughout the country (FADSP, 2018a).


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21 The emergence of the 15-M phenomenon in Madrid and other Spanish cities in 2011, asan outburst of indignation against neoliberal austerity policies, was the mostremarkable episode of social mobilization in defense of the welfare state in Spain sincethe introduction of democracy. The enormous discontent that followed repeated casesof corruption in the largest parties (PSOE and PP) contributed to the birth ofmovements of outraged citizens, collectively known as mareas blancas (white tides).Organized regionally, the movement mobilizes citizens in defense of the SNHS, againstcuts and privatization plans, and also provides a channel by which citizens can expresstheir will, in the absence of effective citizen representation on the governing bodies ofthe regional health systems (Matos and Serapioni, 2017).

22 The first white tide was organized in Madrid in response to the regional PPgovernment’s decision to privatize hospitals and primary care centers. Healthprofessionals played a critical role in the formation and activity of the white tide, theirlegal and media work being particularly powerful; they were able to document theconflicts of interest of politicians promoting privatization initiatives and the privatecompanies that were likely to benefit from them (Sánchez-Bayle and Fernández-Ruiz,2018). Ultimately, the social mobilizations, together with a series of judicial rulings,brought a halt to the most visible privatization initiatives (6 hospitals and 26 primarycare centers) in 2014 and led to the resignation of the PP politicians involved. Thisvictory was an enormous incentive and led to the formation of several white tides inother regions, provinces and municipalities. These tides are still active in many parts ofSpain.

23 Amongst the achievements of the white tides, it is worth highlighting the fact that theprivatization and dismantling of the health system are now on the agenda of politicalorganizations and state institutions. The white tides have shown that when citizenmobilization is unified, massive and sustained, it can paralyze privatization processes(Beiras and Sánchez-Bayle, 2015). The huge deterioration in the working conditions ofhealth workers, especially in primary care, has led to a reaction that is taking shape aswe write this text – in late 2018 – but includes strikes and demonstrations by healthprofessionals in several Autonomous Communities (FADSP, 2018b).

24 The activities of white tides have not been limited to defending the SNHS andattempting to reverse budget cuts: “[...] we have started to talk about and act on healthand not only on disease but on its determinants and on health inequalities” (Martí,2018). They also claim to have “introduced the need to stop the progressivemedicalization of the SNHS, promoted by the health insurance industry and the bigpharma-techno-industrial complex” (Burlage et al., 2018: 70).

25 During the dismantling of the social state, the white tides have helped to open up apublic space where conflicts can be discussed, solidarity can be generated or a commonwill to cope with the uncertainty and suffering generated by the neoliberalindividualizing of stress can be articulated (Solé Blanch, 2018). In the face ofcontemporary capitalism, with its hostility to life, the defense of justice and equityremains the objective for the white tides and similar citizens’ movements.


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Part 2. Impact of the Crisis on Health and HealthInequalities in Spain

26 Before addressing the special features of the Spanish case, we need to consider somecontext-specific factors and methodological considerations that have been raised inrelation to the apparent inconsistencies in the associations between crises andsubsequent health outcomes (Suhrcke and Stuckler, 2012). First, there have beennational differences in the impact of economic crises that appear to be related to thegenerosity of state welfare protection (Norström and Gronqvist, 2015). Second, a widerange of mortality and morbidity indicators has been employed to measure impact,limiting the comparability of studies. Third, the direction of associations found maydepend on whether they are based on individual or aggregated data (Martikainen andValkonen, 1996). Fourth, the health consequences of the ‘normal’, less dramaticvariations in the trade cycle may differ substantially from those occurring underexceptional circumstances, such as the recession we are currently experiencing (Ruhm,2016). Fifth, the short- and long-term health effects of crises, especially on longevity ormortality, may diverge. Finally, one of the main methodological considerations is thedifference between average effects in the population and specific group effects(Marmot and Bell, 2009). When considering this aspect, caution should be applied to thesocio-economic variable used in the analysis of health inequalities. For instance, one ofthe characteristics of the recession in Spain is that young adults have been more deeplyaffected by unemployment and income reductions than other adults. Hence there hasbeen an increase in the numbers of healthier young people in lower income brackets,combined with an increase in older adults – who have benefited from stable pensionsbut have more health problems – in higher income brackets, yielding a reduction inincome-related health inequalities, as shown in a recent study assessing incomeinequalities in self-rated health (Coveney et al., 2016). In the following subsections, wepresent a summary of the main effects of the crisis and austerity measures oninequality in key health outcomes.

Mental Health Outcomes

27 The impact of the Great Recession on mental health in Spain has been thoroughlyinvestigated since its onset. With some exceptions, researchers have used repeatedcross-sectional studies, extracting data from population-based surveys, such as theNational Health Survey. The vast majority of studies report an unambiguous negativeassociation between the recession, subsequent neoliberal measures and mental health.

28 A longitudinal study based on primary data from GP consultations between 2006 and2010 (Gili et al., 2013) represented a milestone in research into the impact of therecession on mental health. Gili et al. reported that mood disorders increased by 19%and anxiety disorders by 8% and that both were particularly frequent in familiesexperiencing unemployment and mortgage payment difficulties. Multi-countryresearch based on the European Social Survey (2006-2014) revealed that the negativeconsequences of the recession for mental health (measured by depressive feelings)were evident in Spain and recommended that particular attention should be paid to theeconomically inactive and precariously employed (Reibling et al., 2017). Anotherpublication based on the same data source found that Spaniards showed low social


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optimism and high levels of depressive symptoms, and attributed the deterioration inmental health over the period 2008-2013 to the financial crisis (Chaves et al., 2018).

29 Several studies have found an increase in the prevalence of poor mental health duringthe crisis period compared with the pre-crisis period. This increase has been attributedto individual-level changes in unemployment (Bartoll et al., 2014), income (Tamayo-Fonseca et al., 2018) or both (Moncho et al., 2018) and to contextual-level changes in theprevalence of precarious employment and lower health spending per capita (Ruiz-Pérez et al., 2017a). Research into sex differences found that the recession has had agreater impact on men’s mental health (Bacigalupe et al., 2016; Moncho et al., 2018).

30 A study using four waves of data from the Basque Health Survey (1997‑2013) did notobserve any association between employment status or social class and the increase inpoor mental health (Bacigalupe et al., 2016). This lack of association was corroboratedby another study in Andalusia which, instead, found that the negative impact of therecession on mental health was concentrated amongst those with secondary education,whether employed or unemployed (Córdoba-Doña et al., 2016)

31 The impact of the financial crisis on mental health appears to have differed betweenage groups. Specifically, the risk of suffering from mental health problems for childrenwith unemployed parents was higher in 2011 compared to 2006 (Arroyo-Borrell et al.,2017). However, the apparent effects of the crisis on the mental health of the youngpopulation vary according to the data source (Aguilar-Palacio et al., 2015; Medel-Herrero and Gómez-Beneyto, 2017). Finally, education- and income-related inequalitiesamongst the over-50s in Catalonia were found to have increased from 2006 to 2015(Spijker and Zueras, 2018). Suicide and Suicidal Behavior

32 Spain has for decades had low suicide rates relative to the European average. Althoughin the wake of the recession several countries have seen an increase in suicides or achange to the previous downward trend (De Vogli et al., 2013), it is not entirely clearwhat the situation in Spain is. López-Bernal et al. (2013) reported an 8% increase insuicides based on an interrupted time series analysis with several methodologicaldrawbacks, including the limited time span 2010‑2015. Ruiz-Pérez et al. (2017b) foundthat the financial crisis was associated with suicides at two different times – thedouble-dip recession – and not with a sustained trend after its onset. In contrastÁlvarez-Gálvez et al. (2017), who measured monthly rates, observed an increase in theperiod 2011‑2014 but not before then, suggesting that the impact of economic problemson suicide may have been delayed by policies designed to mitigate their effects. Theseresults are consistent with an earlier study by Ruiz-Ramos et al. (2014), who reportedthat suicide rates in Spain had decreased between 1999 and 2011, in both men andwomen.

33 The lack of an overall increase in the suicide rate was also observed in Catalonia from2010, although there were increases in several subgroups (Saurina et al., 2015). A studyperformed in the Basque Country and the city of Barcelona showed that educationalinequalities in male suicide have remained broadly stable between 2001 and 2012(Borrell et al., 2017). A study covering the period 1999 to 2013 showed that before thecrisis there was a correlation between unemployment and suicide that has weakenedduring the recent financial crisis (VV. AA., 2017). Interestingly, in contrast with the


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variability in suicide mortality, there has been a consistent increase in attemptedsuicide since the Great Recession, especially in the working age population (Córdoba-Doña et al., 2014; Celada et al., 2017). Mortality

34 According to the majority of authors, overall mortality in Spain has not changed sincethe Great Recession, although there is some controversy about the rate of declinerelative to the pre-Recession trend (Regidor et al., 2014; Ruiz-Ramos et al., 2014; Tapia-Granados, 2014) and in relation to specific causes of mortality and age groups. Forinstance, it has recently been reported that cancer mortality has been decreasing moreslowly since the onset of the crisis (VV. AA., 2018b), while amenable mortalitydecreased more significantly than overall mortality between periods, though unevenlydistributed among causes of death (Nolasco et al., 2018). Moreover, an earlier studyreported that in persons aged 60 years or older mortality appears to be decreasingmore slowly than would have been expected had the recession not occurred(Benmarhnia et al., 2014).

35 At European level, crisis-related economic conditions were not associated withwidening health inequalities in mortality until 2014 (VV. AA., 2018c). However, thisconclusion is not supported by the results of several studies based on local and regionaldata. In Andalusia, social inequalities in male mortality have increased since the earlyyears of the crisis and this is linked to a deeper reduction in mortality rates amongstmore educated men (Ruiz-Ramos et al., 2014). A study which took an ecologicalapproach to mortality found that between 2008 and 2011 it increased more relative tothe pre-crisis period in deprived neighborhoods of Barcelona than in affluentneighborhoods (Maynou Pujolras et al., 2016). However, it remains to be determinedwhether deaths from specific causes may have been disproportionately affected by therecession in specific vulnerable subgroups (Alonso et al., 2017). Immigrants’ Health and Healthcare

36 One of the first assessments of the impact on the Great Recession on immigranthealthcare access in Spain (covering 2006‑2012) did not find any deterioration, possiblybecause the SNHS performed fairly well until 2012 (García-Subirats, 2014). Using thesame databases, Gotsens et al. (2015) found that immigrants who arrived in Spain before2006 had worse health status than natives and posited that the recession wasresponsible for the loss of the so-called healthy immigrant effect.

37 Cimas et al. (2016) evaluated the implementation of the above-mentioned Royal Decree-Law 16/2012 of the Spanish government, which limited immigrants’ previouslycomprehensive access to public health services. They found that implementation variedgeopolitically, reflecting the complexity of nation-wide regulation in a highlydecentralized system (ibidem). A more recent review also showed that regionallegislation protecting the rights of undocumented migrants may have limited thedeleterious health effects of the recession and subsequent austerity measures on thisgroup (Peralta-Gallego et al., 2018). One of the few publications to compare native andmigrant populations found that immigrant women and men were more likely to use GPand emergency services than their native counterparts (Rodríguez-Álvarez et al., 2018).


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38 There are limits to how effectively one can assess immigrants’ access to healthcareservices using quantitative data extracted from population-based surveys. A qualitativestudy designed to address the drawbacks of quantitative research found anexacerbation of pre-existing barriers to the use of healthcare services and theappearance of new obstacles to entering the healthcare system in the wake of the crisis(Porthé et al., 2016), as well as a decline in the perceived quality of the technical andinterpersonal resources of the health services during the economic crisis (ibidem, 2018). Children’s Health

39 A comparative study of the Catalonian Health Surveys for 2006 to 2010, and 2012, foundthat although some health-related behaviors improved during the study period,childhood obesity increased and inequalities in health-related quality of life increasedin children under 15 years of age (Rajmil et al., 2013).

40 Interestingly, two publications from 2018 focused on perinatal outcomes in Spain,covering 2002 to 2013 (VV. AA., 2018d) and 2007 to 2015 (Terán et al., 2018), andobserved that the prevalence of small-for-gestational-age births has increased duringthe crisis, interrupting the previous downward trend. In addition, the pre-crisisinequalities in perinatal health have persisted, although low birth weight proved to bemore strongly associated with maternal educational level after the onset of the crisisthan in the previous period (ibidem). These findings are consistent with a broadly-basedstudy using data for 2005‑2015 from 16 European countries. This study concluded thatcountries that implemented more severe austerity measures have experienced anincrease in the prevalence of low birth weight together with an increase in materialdeprivation in families with no more than primary education (Rajmil et al., 2018). Use of Healthcare Services

41 López-Valcárcel and Urbanos-Garrido have studied a wide variety of health serviceperformance indicators during the crisis and related them to diverse socioeconomicvariables. Their research, together with contributions from other scholars, is includedin a very recent comprehensive review, edited by the Spanish Ministry of Health, of theimpact of the current economic recession on health and use of healthcare services(Ministerio de Sanidad, Consumo y Bienestar Social, 2018a).

42 The overall use of health care services was unchanged during the early years of thecrisis, although a study by Urbanos-Garrido and Puig-Junoy (2014) described howwaiting times and waiting lists for surgery increased, in parallel with the increase indissatisfaction with the SNHS that has been detected in health surveys. Morespecifically, the average waiting time for surgery rose from 63 to 76 days between 2009and 2012 (López-Valcárcel and Barber, 2017) and increased further to 93 days in June2018 (Ministerio de Sanidad, Consumo y Bienestar Social, 2018b).

43 No significant socioeconomic differences in the frequency of use of physicianconsultations and hospitalizations in Spain were observed in 2007 or 2011 (Lostao et al.,2017). Using the same data (from the Spanish Health Survey) Abásolo et al. (2017) foundthat, in relative terms, the recession has had a greater detrimental effect – a decreasein utilization – on low-income groups with respect to specialist appointments and


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hospitalizations, whereas it has worked to their advantage with respect to emergencyservices and GP consultations (ibidem).

44 A study in Andalusia, comparing 2007 to 2012, found that horizontal inequity in the useof GPs and specialists had reduced, but argued that the increase in lower incomegroups’ use of hospitalizations and emergency services could indicate that their accessto appropriate primary care services had been curtailed (Córdoba-Doña et al. , 2018).Increases in the use of emergency services associated with poor mental health andlimitations on daily activities in lower income groups have also been reported (Pereiraet al., 2016). Non-attendance to dental visits by lower social classes has increased,leading to a steeper social gradient in the use of dental services (Calzón-Fernández etal., 2015). Finally, the Health Barometer data from 2014 to 2016 showed thatunemployed people were four times more likely to discontinue medication becausethey could not afford it than qualified workers and professionals, which raisesimportant questions about equity of access to treatment (Ministerio de Sanidad,Consumo y Bienestar Social, 2018a).

Conclusions

45 This extended historical contextualization and review of the literature add to thegrowing body of research that indicates that the Great Recession and neoliberalausterity measures have so far had a deleterious impact on mental health and suicidalbehavior, especially in the middle-aged Spanish population. We highlight theimportance of these findings, often disregarded in favor of research that focuses toomuch on the weak or unclear effects of the recession on general mortality and self-rated health.

46 Although it is not yet possible to observe all the health consequences of the GreatRecession, it seems very plausible that the aggravation of social inequalities duringthese years, and the detrimental effect on other structural and proximal determinants,will be translated into medium- and long-term negative effects on health, with thelatency depending on the nature of the health outcome in question. For example, it isonly very recently, several years into the recession in Spain, that increases in poorperinatal outcomes have been reported. The observed effects of the recession appear tobe mediated by unemployment, loss of access to housing and economic hardship, all ofwhich disproportionately affect vulnerable populations. The effects on healthinequalities will also depend on the indicators of socio-economic position employed. InSpain, the young population – which is relatively highly educated – has suffered mostfrom increased unemployment, precarious jobs and cut wages and this is why we seeparadoxical results such as the reduction in income inequality, alongside an increase ineducational inequality in some health outcomes.

47 In general, the results relating to equity in the use of health services indicate that theSNHS showed considerable resistance to the effects of recession during the early years,primarily as a result of professionals absorbing the extra burden at the cost ofoverstraining themselves. Some indicators – such as the growing dissatisfaction of thepopulation – suggest that by 2013 the system’s buffer capacity was exhausted. Althoughinequalities in access to medication and timely admission to services are beingdetected, with the information currently available it is not possible to assess the impacton health outcomes that is due to deterioration in the quality of services directly. The


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deleterious effects on immigrants’ access to healthcare are clear from qualitativeresearch carried out in recent years, although the high regional variability in theimplementation of restrictive measures prevents us from reaching an overallconclusion.

48 Finally, if we put the Great Recession and the consequences that have flowed from itinto a broad temporal perspective, it does not seem appropriate to consider the crisisor recession as a specific event or a temporary variation/fluctuation occurring in acertain country. We propose that the world has entered a new, qualitatively differentera, as these changes are taking place in the context of a global crisis (climatic, culturaland social) that affects the majority of the structural determinants of health and healthinequalities in multiple ways. We would strongly suggest/claim that the oxymoron“relentless crisis” can be applied to the situation in the countries of Southern Europe –and to the global South – and argue that the only way out is policies directed towards“the causes of the causes” of inequalities in health. This implies that the welfare ofpeople must be central, and that achieving this is a complicated challenge in thecurrent phase of capitalism.

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ABSTRACTSSpain is generally regarded as one of the European countries most affected by the GreatRecession starting in 2008 and subsequent restrictive policies. In the first part of this paper weattempt to understand the impacts of the crisis on the welfare state that have led to healthinequalities, with a special emphasis on the history of the Spanish National Health System frommid-twentieth century onwards. We also examine citizens’ responses to austerity measureswithin the health system, highlighting the role of the “white tides” movement. In the second partof the paper, we provide a selective review of the main findings on the effects of the GreatRecession in the country, focusing particularly on its outcomes on mental health and oninequalities in health and healthcare use. We conclude that key policies need to be directedtowards “the causes of the causes” of health inequalities, a complicated challenge in the currentphase of capitalism.

A Espanha é geralmente vista como um dos países europeus mais afetados pela Grande Recessão eas subsequentes políticas restritivas. Neste artigo, tentamos, em primeiro lugar, compreender osimpactos da crise no Estado-Providência, que levaram a desigualdades na área da saúde,centrando-nos sobretudo na história do Sistema de Saúde Nacional espanhol desde meados doséculo passado. Também analisamos as reações dos cidadãos às medidas de austeridade nosistema de saúde, salientando o papel do movimento das “marés brancas”. Num segundomomento, apresentamos uma análise seletiva dos principais dados sobre os efeitos da GrandeRecessão no país, centrando-nos em especial nos resultados sobre a saúde mental e nasdesigualdades na saúde e na utilização do sistema de saúde. Concluímos que as principaispolíticas têm de ser direcionadas para “as causas das causas” da desigualdade na saúde, o que éum desafio complicado na fase atual do capitalismo.

INDEX

Keywords: austerity measures, economic crisis, health inequalities, mental health,socioeconomic factors, SpainPalavras-chave: crise económica, desigualdades em saúde, Espanha, fatores socioeconómicos,medidas de austeridade, saúde mental

AUTHORS

JUAN ANTONIO CÓRDOBA-DOÑA

Unidad de Medicina Preventiva y Salud Pública, Hospital Universitario de Jerez, Área de GestiónSanitaria de Jerez, Costa Noroeste y Sierra de Cádiz | Instituto de Investigación Biomédica eInnovación de Cádiz, INIBICARonda de Circunvalación, s/n., Jerez de la Frontera, 11407 Españ[email protected]

ANTONIO ESCOLAR-PUJOLAR

Consejería de Salud de la Junta de Andalucía, Delegación Territorial en Cádiz (retired)Cádiz, Españ[email protected]


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Crisis, salud y calidad de vida.Algunas evidencias en España yPortugalCrisis, Health and Quality of Life. Some Evidences from Spain and Portugal

Elena Cachón González

NOTA DEL EDITOR

Recibido: 20.02.2019Aceptación comunicada: 23.06.2019

Introducción

1 En sociedades más igualitarias, los seres humanos son generalmente más felices y mássanos. Además, cada vez hay más evidencia empírica que demuestra que una mayorigualdad económica beneficia a toda la sociedad, tanto si eres rico como si eres pobre.Más igualdad significa avanzar hacia que todas las personas sean recompensadas por eltrabajo que realizan y sean atendidas las necesidades que tienen (Dorling, 2017: 9-12). Yesto es justo lo contrario de lo que ha pasado en la Unión Europea durante la crisis,pero especialmente en los países del Sur de Europa, tal y como ponen de manifiesto laevolución de los datos del Índice de Gini para estos países en comparación con la mediade la Unión Europea de los 28 (UE 28) (véase Gráfico I).


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GRÁFICO I – Índice de Gini (2010-2016)

Fuente: elaboración propia a partir de Eurostat (2016).

2 Entre los años 2010 y 2016 el Índice de Gini, en la Unión Europea, aumenta 0,3 puntos,mientras que en Portugal lo hace 0,2 puntos, en Grecia e Italia aumenta 1,4 puntos, ycrece 1 punto en España. Ahora bien, si se analiza el valor medio de este indicador enesos años, frente al 30,7 de la UE 28, España alcanza el 34,2, seguido de Portugal, con un34,1, Grecia con un 34 e Italia con un 32,5, lo que pone de manifiesto que lasdesigualdades se han ido extendiendo en el sur de Europa a lo largo de los últimos años.Además,

la persistencia de desigualdades sociales en relación con la salud es un hechocontrastado: las personas con mayor nivel educativo, mayor categoría profesional, omayores ingresos, tienen tasas más bajas de morbilidad y una esperanza de vidamás larga. […] la intensidad de estas desigualdades varía de un lugar a otro, yexisten notables diferencias dentro de Europa. (Eikemo et al., 2016: 3)

3 Tal y como demuestran Wilkinson y Pickett (2010: 24), el deterioro de la salud corre enparalelo a las desigualdades económicas, puesto que sus resultados evidencian que losproblemas de salud y los problemas sociales son más acuciantes en países con mayordesigualdad de ingresos. Y esta situación es especialmente preocupante en Portugal,que, según Wilkinson y Pickett (2010), ocupa el penúltimo lugar en el ranking de paísescon mayor desigualdad de ingresos, solo por detrás de Estados Unidos. En este sentido,Serapioni (2017: 7-9) apunta a que en los países del sur de Europa son la educación, losingresos y la condición laboral los factores determinantes de las desigualdades en salud,es decir, que el componente social es su factor decisivo.

4 Según Eikemo et al. (2008: 566), las personas con menor nivel educativo reportan peorsalud, mayores tasas de infecciones y una esperanza de vida menor que aquellas quetienen mayores niveles educativos. Además, ponen de manifiesto que dentro de Europael impacto de las desigualdades educacionales en la salud varía. Sus resultados apuntana que en el sur de Europa las desigualdades en salud son mayores que en el resto depaíses europeos, en línea con estudios como el de Husiman et al. (2003) que concluyenque las menores desigualdades se dan en países como Holanda, Bélgica o Francia, y lasmayores en Italia, Grecia y España, o el de Van Doorslaer y Koolman (2004) que apuntan


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a que en Portugal se dan extensas diferencias en la salud autorreportada en relacióncon los ingresos.

5 Los datos ponen de manifiesto que las personas con niveles socioeconómicos más bajos,tienen peor salud, si bien hay distintos patrones de desigualdad en Europa, tal y comomuestra el Gráfico II, en el que se observan dos hechos diferenciados: el primero, queexisten grandes diferencias entre España y Portugal, puesto que en España la poblacióncon problemas de salud declarados parece evolucionar en paralelo con los ciclos de lasituación macroeconómica, mientras que en Portugal, la situación muestra unatendencia al alza a lo largo de toda la crisis; el segundo, que en ambos países se observaque es la población de los quintiles de ingresos más bajos los que reportan peor salud alo largo del periodo 2008-2017. GRÁFICO II – Población de 16 o más años con problemas de salud o enfermedades de larga duración,primer y quinto quintil de ingresos (España y Portugal, 2008-2017, en %)

Nota: los datos de cada persona se ordenan de acuerdo con el valor del ingreso disponible equivalentetotal. Se identifican cuatro valores de punto de corte (los llamados puntos de corte del quintil) deingresos, dividiendo la población de la encuesta en cinco grupos representados por igual por el 20 %de los individuos cada uno, cinco grupos que se corresponden con los cinco quintiles. El primer grupode quintiles representa el 20 % de la población con el ingreso más bajo (un ingreso menor o igual alprimer valor de corte), y el quinto grupo de quintiles representa el 20 % de la población con el ingresomás alto (un ingreso mayor que el cuarto valor de corte).Fuente: elaboración propia a partir de Eurostat (2016).

El contexto: la crisis económica

6 La austeridad en Europa fue una opción, una alternativa elegida. Estados Unidos yJapón no optaron por la austeridad para gestionar la crisis, sino por políticas quelimitaran el impacto de la crisis financiera en la economía real, el empleo y la calidad devida. En cambio, en la Unión Europea, la crisis de la deuda sirvió de pretexto paraimponer la austeridad fiscal y las políticas de devaluación interna en determinadospaíses, insistiendo en las políticas de oferta, y subestimando el papel de la demanda yde la distribución del ingreso y la justicia social.


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7 Las políticas aplicadas en los últimos años, aunque con diferente intensidaddependiendo de los países, tienen dos elementos en común: el ajuste fiscal traducido enla austeridad, y la mejora de la competitividad y del empleo vía reducción de los costessalariales (Schulten y Müller, 2014). En este sentido, la política europea consideró que elpapel conjunto de la austeridad y la mejora de la competitividad eran los elementosclave para salir de la crisis, y fueron los salarios el elemento central de ajuste para lamejora de la competitividad nacional en las economías europeas.

8 Así las cosas, las crisis se convirtió en la oportunidad para aprobar reformasestructurales que han afectado esencialmente a asalariados, funcionarios públicos,jubilados y beneficiarios de prestaciones sociales. Se han privatizado los serviciospúblicos, especialmente en países con mayores dificultades; se han recortado laspensiones, se ha aumentado la edad de jubilación y se han reducido las tasas dereemplazo; además, se ha debilitado la protección de los asalariados a través de ladesregulación de sus condiciones laborales y de mayores niveles de flexibilidad laboral,mediante medidas que fortalecen la flexibilidad de los contratos y empleos "atípicos" yla gestión del tiempo de trabajo por parte de los empleadores, que facilitan los despidosy que limitan las prestaciones por desempleo, reduciendo por un lado los subsidios yendureciendo por otro lado las condiciones de acceso (Triantafillou, 2014).

9 Como señala Degryse (2014: 22), a partir de diciembre de 2009, a la crisis de la deudagriega, le siguieron, entre otros países, España y Portugal, y finalmente, toda laEurozona. En 2010, la Unión Europea anuncia, en coordinación con el Banco CentralEuropeo y el Fondo Monetario Internacional, un plan de ayuda para Grecia, con unacontrapartida: la austeridad exigida por la nueva gobernanza económica europea y elcontrol exhaustivo del déficit. A través de la reforma del Pacto de Estabilidad yCrecimiento, e implementando lo que se conoce como Semestre Europeo (cuyo objetivoinicial era fortalecer la coordinación de las políticas económicas entre los Estadosmiembros), la Unión Europea aumentó la supervisión de los presupuestos nacionales,con el fin de garantizar la coherencia ex ante entre ellos y con los compromisosadquiridos a nivel europeo.

10 De este modo, los Programas Nacionales de Reformas a partir de 2011 contienenmedidas destinadas principalmente a controlar el gasto público y a mejorar sueficiencia, a recortar salarios y pensiones públicas, y a congelar contrataciones en elsector público. En relación con la atención médica, las medidas se centran en reducir elgasto, mediante el establecimiento de mecanismos de control y la limitación dedeterminados gastos, como los suministros farmacéuticos, entre otros.

Efectos de la crisis económica en la sanidad

11 En países como Portugal el sector de la sanidad fue inicialmente asolado por lasmedidas de austeridad, pero a medida que se desarrolló la crisis, se fueronimplementando numerosos recortes del gasto en los presupuestos (Gool y Pearson,2014: 19). Análisis como el de Jiménez-Martín (2014: 33) señalan que “el contrasteexistente entre la variación del gasto total en sanidad en el periodo 2000-2009 y elperiodo 2009-2012 muestra con claridad el golpe de la crisis económica”. Y sigue:

Son varios los países que han experimentado recortes en el gasto sanitario y en lamayoría, si ha habido crecimiento, éste ha sido escaso. En España, el gasto sanitariototal ha caído un 5 % en el periodo 2009-2012 al igual que Portugal (-4 %), viéndose


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sólo superado por Grecia (-24 %) e Irlanda (-10 %) justamente el resto de losintegrantes del conjunto de países parcial o totalmente rescatados. Sigue de cercaItalia, que siempre estuvo en un tris de ser también rescatada. (ibidem)

12 Además de la austeridad, y los recortes de gasto público sanitario asociados, la gestiónde la crisis económica en la sanidad en Europa se ha caracterizado también por unanueva gestión, traducida en el ahorro de costes y el aumento de la eficiencia en lafinanciación y la provisión publica de cuidados de salud (Popic et al., 2019: 744).

13 Tanto en España como en Portugal se aplicaron medidas en relación distintos ámbitossanitarios. Por ejemplo, en cuanto la financiación pública del sistema sanitario, enPortugal se incrementó un 1 por ciento el IVA en determinados medicamentos; enrelación con la cobertura sanitaria, en España se redujeron los servicios a los que podíaacceder los inmigrantes indocumentados, mientras que en Portugal se excluyerondeterminados medicamentos de la cobertura farmacéutica y se aumentaron los costesde los usuarios de algunas vacunas, así como de determinadas medicinas relacionadascon la salud mental. Por otro lado, se revisaron los precios de los fármacos en ambospaíses con reformas como la reducción del 30 % del precio de los medicamentosgenéricos en España, o la investigación de los precios pagados a las farmacéuticas poralgunos medicamentos cubiertos por la sanidad pública en Portugal. Pero también serevisaron los “precios” de los trabajadores de la sanidad, o recortando el sueldo de losfuncionarios de la sanidad pública en España y Portugal y recortando a la mitad elsalario de las horas extras en Portugal. Otras medidas se centraron en la oferta delsistema sanitario, como la reducción del número de camas hospitalarias, tanto enEspaña como en Portugal, o la racionalización de los servicios hospitalarios y loscentros de salud (Gool y Pearson, 2014: 21-22).

14 La evidencia muestra que todas estas políticas de austeridad aplicadas en Europa hanresultado económicamente ineficientes y socialmente injustas, puesto que hanaumentado las desigualdades, especialmente entre los más vulnerables (Triantafillou,2014). Por ejemplo, en el caso de España, los datos del Decil del Salario Principalderivados del Encuesta de Población Activa ponen de manifiesto que entre 2009 y 2016el 10 % de los trabajadores con menores retribuciones han sufrido una caída del 14 % ensus salarios reales; el segundo decil ha perdido un 10 % y el tercero, un 8 %. En decir, lostrabajadores con menores ingresos son los que han sufrido un mayor ajuste salarial, demodo que aumentan las desigualdades y a la vez las situaciones de pobreza y exclusiónsocial.

15 Según Oliva et al. (2018: 56), en España “algunos problemas de salud […] tienen ungradiente social claro que parece haber aumentado durante la crisis”. Además, losresultados sobre las necesidades médicas no cubiertas ponen de manifiesto un clarogradiente social durante los años analizados (2004-2016), que perjudica a la poblacióneconómicamente más desfavorecida y que es la más afectada por la crisis. Y continúaconcluyendo que

la desigualdad se redujo de forma importante antes del comienzo de la GranRecesión, entre los años 2004 y 2007, llegando los índices a alcanzar valorespositivos en este último año. En 2007 y 2008 el gradiente social deja de sersignificativo, pero vuelve a aumentar de forma continuada hasta el año 2014,momento en que esta tendencia comienza a revertirse nuevamente. A partir de2015, un año después de que se inicie la recuperación económica, la desigualdaddeja de ser significativa, retornando a la situación inmediatamente anterior a lacrisis. (Oliva et al., 2018: 183)


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16 En esta línea apunta Jiménez-Martín (2014: 10), al señalar que, a pesar de que losindicadores sobre el estado de la salud en España no han sufrido deterioro alguno entrelos años 2007 y 2013, sí lo han hecho los indicadores indirectos de riesgos para la salud,como la pobreza o la desigualdad, factores determinantes de la salud a medio y largoplazo, que

han empeorado sustancialmente en estos años, 3,5 y 4,1 puntos porcentuales,respectivamente […]. En consecuencia, si no se pone remedio rápidamente, dichosaumentos, agravados con las restricciones de acceso a servicios introducidos en2012, pueden derivar en empeoramientos sustanciales de la salud de los individuosmás desfavorecidos. Es decir, puede inducir en un aumento en las inequidades ensalud entre la población española. (ibidem: 31-32)

17 Los datos no dejan lugar a dudas: tanto en España como en Portugal, el gasto público encuidados sanitarios (calculado en euros por habitante) está muy lejos de los nivelesanteriores a la crisis, tal como muestra el Gráfico III. Como señala Lobato (2011: 97), noexisten dudas sobre el hecho de que las crisis, sean de naturaleza financiera,económica, política o social (y la Gran Recesión ha tenido las cuatro dimensiones),afectan de forma directa e inequívoca al estado de salud de la población.

GRÁFICO III – Variación anual del gasto público en cuidados sanitarios (euros por habitante)


18 Según los datos de Eurostat (2016), España parte de un aumento del gasto en 2008 del9,3 %, mientras que Portugal se sitúa en el 4,4 %, y aumenta en 2009 hasta el 5,7 %. Apartir de ese año, ambos países muestran una tendencia a la baja, que toca fondo en2012 con caídas del 5,3 % del gasto por habitante en España y del 9% en Portugal. Desde2013 inician una lenta recuperación, que alcanza los niveles de gasto por habitante deantes de la crisis en Portugal, con un aumento del 5 % en 2016, pero no así en España,donde en 2016 el aumento del gasto fue del 1,7 %. En definitiva, la respuesta de lasanidad pública se ha debilitado tanto en España como en Portugal, países ambos conenormes desigualdades, envejecimiento creciente y una peor situación de la salud encomparación con otros países europeos.


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19 Recordemos que la crisis en la Unión Europea es en realidad una crisis múltiple. Lacrisis financiera que estalló en 2007 puso de manifiesto las profundas grietas en laarquitectura de la Unión Económica y Monetaria en Europa, sus defectos deconfiguración, los desequilibrios existentes y sus insuficiencias estructurales. Y en estecontexto, la crisis económica y las políticas aplicadas agravaran esos desequilibriosestructurales existentes en los distintos países, mientras que la recapitalización de losbancos agravó los déficits públicos de distintas economías europeas. Además, la crisisde la deuda en 2010 en Grecia se extendió rápidamente a Irlanda y Portugal primero, y aEspaña e Italia después, y los factores internos específicos en cada país y en cadaeconomía terminaron por dibujar una gestión nacional de la crisis bajo el paraguas delas mismas responsabilidades de la política europea en esa gestión (Triantafillou, 2014).

20 Dado que el desarrollo de las políticas públicas no es neutral, las desigualdadesrelacionadas con la salud se volvieron prioritarias en los países del sur de Europa apartir de los años 2010-2011, cuando se pusieron de manifiesto los efectos sociales delas políticas de austeridad impuestas por las instituciones europeas e internacionales(Serapioni, 2017: 2).

21 Según Karanikolos et al. (2013: 1327), la crisis en Europa ha planteado grandes amenazaspara la salud, por ejemplo, en cuanto al número de suicidios o nuevos brotes deenfermedades infecciosas, puesto que la conjunción de la austeridad fiscal y la debilidadde la protección social tiene como consecuencia el aumento de riesgos para la salud,tanto sociales como individuales.

22 Pero además de los efectos objetivos de la crisis en la sanidad, y tal y como señalaSerapioni (2017: 9), las políticas de austeridad han tenido una serie de efectos subjetivos,dado que aumentaron la insatisfacción con las prestaciones sanitarias en todos lospaíses europeos, pero particularmente en Grecia, como resultado del retroceso sinprecedentes del gasto público, y en Portugal, reflejo del declive drástico de lasprestaciones, pero también fue significativo en España e Italia, dada la contraccióntanto en el gasto como en las prestaciones.

23 Esta situación objetiva tiene efectos subjetivos que se manifiestan en las percepcionesde los ciudadanos. En este sentido, Jiménez-Martín (2014: 39) señala que, en España,según datos de los Barómetros Sanitarios 2006-2013, a pesar de que la mayoría de lapoblación se encuentra satisfecha o muy satisfecha con el sistema sanitario en España,las tendencias muestran que la valoración del sistema ha evolucionado en paralelo a losrecortes. En este sentido, Bartoll et al. (2015: 7-8) apuntan a que en España los niveles desalud autorreportada han mejorado en el periodo 2011-2012, tanto entre lostrabajadores ocupados como entre los trabajadores desempleados, si bien la mejora hasido menor en éstos últimos, pero subrayan que parte de la explicación es que lostrabajadores ocupados reportan mejores niveles de salud debido al miedo a serdespedidos en un contexto de desempleo generalizado.

24 Según Eurofound (2014: 65), la puntuación global de satisfacción con la salud en laUnión Europea en 2001 fue de 7,3 puntos (en una escala de 1 a 10), la misma que en2007, y destaca el hecho de que entre los mayores incrementos en satisfacción con lasalud entre 2003 y 2011 se encuentra Portugal, con casi medio punto de mejora en esosaños. En este caso, los datos señalan que la calidad percibida de los servicios de salud haaumentado, de 4,9 en 2003 a 6,3 en 2016, aproximándose así a la media europea en 2016(6,7 puntos); sin embargo, la calidad percibida de los servicios de atención a largo plazoha disminuido, desde los 5,4 en 2011 a los 5,0 en 2016, si bien en Portugal todas las


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calificaciones de calidad sobre sus servicios públicos están por debajo de las mediaseuropeas.

25 En el caso de España, este informe señala que la calidad percibida de los servicios desalud ha mejorado de 6,3 en 2003 a 7,2 en 2016, situándose por encima de la mediaeuropea (6,7 en 2016) solo en este caso, puesto que la valoración del resto de serviciospúblicos en España es similar. Por otro lado, los datos ponen de manifiesto que existeuna relación positiva y significativa entre la calidad percibida de la asistencia sanitariay la satisfacción con la salud. Además, la calidad percibida de la asistencia sanitaria estádirectamente relacionada con las instituciones sanitarias. En aquellos sistemas de saludcon menores niveles de gasto, menos médicos generales y copagos más altos, el nivelgeneral de satisfacción es menor (Eurofound, 2014: 68; Popic et al., 2019: 744). Y este esel caso del sur de Europa.

26 Según los datos integrados de 2003-2016 de la Encuesta Europea de Calidad de Vida deEurofound, Portugal muestra un peor comportamiento en todos los indicadoresseleccionados respecto a la media europea (véase Tabla I). En España, si bien losindicadores de calidad sobre distintos aspectos relacionados con la sanidad sonsuperiores a la media europea, todos los indicadores de satisfacción están por debajo,excepto el de “atención recibida en los hospitales”. TABLA I – Indicadores de calidad y satisfacción de los servicios sanitarios (escala de 1 a 10, datosintegrados 2003-2016)

UE 28 España Portugal

Calidad

Servicios sanitarios 6,18 6,81 5,44

Cuidados larga duración 5,95 6,26 5,20

Médico de familia/centro de salud 7,33 7,43 6,81

Hospitales y servicios de especialista 6,86 7,08 6,45

Satisfacción

Calidad de instalaciones 7,95 7,60 7,13

Profesionalidad de profesionales 8,05 7,74 7,01

Atención recibida 7,99 7,72 6,88

Calidad de instalaciones en hospitales 7,86 7,71 7,41

Profesionalidad de profesionales en hospitales 7,95 7,92 7,22

Atención recibida en hospitales 7,76 7,80 7,05

Fuente: elaboración propia a partir de Eurofound (2014).


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Efectos de la crisis económica en la salud y la calidadde vida

27 A pesar de los efectos de la crisis, la satisfacción con la vida en la Unión Europeadurante la última década se ha mantenido en un nivel relativamente alto, y superó los 7puntos sobre 10 en el año 2016, según la última ronda de la Encuesta Europea deCalidad de Vida (Eurofound, 2017). Sus datos apuntan a que entre los años 2011 y 2016,algunas dimensiones de la calidad de vida recuperaron los niveles anteriores a la crisis,aunque las diferencias entre países siguen siendo extensas, y en países como España,Grecia o Italia, la satisfacción con la vida disminuyó durante este período, al igual quelos indicadores de felicidad. En Portugal, la evolución de la satisfacción con la vida enese periodo ha mejorado, pero no así la de la felicidad, que sigue su tendencia a la baja.

28 En España y Portugal, el impacto de una mala salud en la satisfacción con la vida esnegativo, como cabe esperar, siendo mayor en España (-1,1) que en Portugal (-0,7)(Eurostat, 2016). Según el Índice para una vida mejor1 de la OCDE, entre los años 2011 y2017, en España lo que más preocupa a la población en su vida es la salud (10,8 %),seguida de la educación (10,1 %) y del equilibrio vida-trabajo (9,7 %). Por su parte, enPortugal, lo que más preocupa a la población es la salud, que empata con la satisfaccióncon la vida (10,3 %), seguida de la seguridad (9,8 %). Este índice también analiza lasdesigualdades en el bienestar relacionadas con la salud percibida. Para Portugal, losresultados muestran que las mayores desigualdades se dan entre hombres y mujeres,pero en el caso de España se dan entre los jóvenes y la población de mediana edad. Enambos casos, las causas apuntan a la peor situación laboral y a los menores nivelessalariales y de ingresos. Al explotar los datos de la dimensión salud, los resultadosmuestran que en España el porcentaje de adultos que declaran tener buena o muybuena salud ha aumentado 6 puntos desde 2005, acercándose a la media de la OCDE,mientras que, en Portugal, este porcentaje se ha mantenido estable y por debajo de lamedia de la OCDE. En esa dirección apuntan Huijts et al. (2017), quienes señalan que, enPortugal, el 10% de la población reporta mala o muy mala salud, el 20 % reportalimitaciones por enfermedad y el 23 %, síntomas depresivos. En el caso de España, el 12% de la población reporta mala o muy mala salud, el 17 % reporta limitaciones porenfermedad y el 19 %, síntomas depresivos.

29 En cuanto a los determinantes sociales a los que se exponen los ciudadanos de estos dospaíses, los datos ponen de manifiesto que el 18,7 % de la población de Portugal declarano tener cubiertas sus necesidades de atención sanitaria general, al igual que el 12,4 %de la población en España.

30 En este sentido, según Eurostat,2 en 2016, un 2,5 % de la población en la UE 28 reportócuidados médicos no cubiertos por razones financieras, listas de espera o distanciaelevada para ser atendido. La tendencia en estas necesidades insatisfechas de atenciónmédica no ha sido uniforme a lo largo del tiempo, ya que estas aumentaron entre 2009 y2014, en línea con la reducción de los recursos financieros destinados al sistema desalud. A pesar de que el porcentaje es menor que en años anteriores, los costes semantienen como la razón principal. Conviene señalar que solo un 1 % de la población demayor ingreso reporta esta razón, frente al 5 % del grupo de menor ingreso, y lamayoría son mujeres, mayores y población con menor educación. Pero a pesar de laevolución positiva de la UE en general, en el sur de Europa la tendencia es otra,especialmente en Grecia e Italia, pero también en Portugal. Y si comparamos con la


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situación en España, las tendencias son muy diferentes, tal y como se observa en elGráfico IV. Los datos muestran que la población afectada por las necesidades decuidados médicos no satisfechas es mucho mayor en Portugal que en España, donde lasituación es más favorable que la media europea en todo el periodo. Además, en Españael porcentaje de población que declara necesidades no satisfechas no supera el 0,5 % enel peor momento de la crisis, en el año 2013, mientras que en la UE 28 ese porcentajeaumenta hasta el 2,4 % ese mismo año, y alcanza el 3 % en Portugal en 2014. GRÁFICO IV – Necesidades de cuidados médicos declaradas no satisfechas por razón de coste (% depoblación, 2010-2017)


31 Según O’Donnell et al. (2014: 43), los factores principales que afectan a la satisfaccióncon la vida pueden dividirse en tres grandes bloques: el económico, vía ingresos,educación y empleo; el social, vía relaciones familiares y sociales, valores ymedioambiente; y el personal, vía salud física y salud mental. Y es esta última la queapuntan como el factor personal más determinante para la satisfacción de la vida en losanálisis de corte transversal, y aparece como el predictor más importante, mucho másque la enfermedad física, el ingreso, el empleo o la situación familiar. Y una de lasrazones es su extensión social: el 20 % de la población adulta en las economíasavanzadas tiene un diagnóstico de enfermedad mental, sobre todo depresión y ansiedad(ibidem: 47). Y el desempleo es uno de sus factores determinantes, más por su impactopsicológico que financiero.

32 En este punto conviene recordar que, durante la crisis, el efecto más devastador enEspaña fue el desempleo, que llegó a alcanzar 26,1 % de la población activa en España yal 16,4 % en Portugal en el año 2013. En 2017, los datos cerraron con una tasa de parodel 17,2 y 9,0 %, respectivamente. Dicho de otro modo: el desempleo afectó a casi cuatromillones de trabajadores en España y medio millón en Portugal.

33 Según el informe Índice de Bem-Estar 2004-2016 (INE, 2017), en Portugal el bienestardescendió entre los años 2007 y 2012, y a partir de entonces tuvo una evolución másfavorable. El indicador de “vulnerabilidad económica”, que refleja la pobreza monetaria


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y la privación material, tiene la segunda peor evolución. La evolución más desfavorablecorresponde al dominio “empleo e ingresos”, debido a la situación del desempleo, alsubempleo y a la evolución de los salarios. Además, el informe alerta de que estasituación se intensifica a partir de 2009, y no es hasta 2013 cuando empieza a mostrarun mejor comportamiento. En cuanto al dominio “salud”, y a pesar de que es elcomponente con la cuarta mejor evolución, ésta fue mucho más positiva en los añosanteriores a la crisis que en los posteriores a la misma.

34 Otro de los efectos de la crisis que merece la pena destacar de relación con la salud, esla evolución de la salud mental. Estudios como los de Thomson et al. (2015: 37) oPetmesidou y Guillén (2014: 304) muestran como la crisis aumentó los problemas desalud, sobre todo de salud mental, entre los colectivos menos favorecidos, yespecialmente en las sociedades europeas del sur, como es el caso de España y Portugal(Karanikolos et al., 2013: 1328; Ruiz-Pérez et al., 2017: 6). Las personas más vulnerablesson aquellas que están en países donde se producen mayores recortes en el presupuestopúblico y aparecen tasa de desempleo creciente, porque la conjunción de la pérdida delempleo y el miedo a perderlo tienen efectos adversos para la salud mental, efectos quese han evidenciado en Grecia, España y Portugal (Karanikolos et al., 2013: 1328;Urbanos-Garrido y López-Valcárcel, 2015: 182).

35 Como señalan Hemingway et al. (2013: 8), las relaciones entre la recesión económica ylas condiciones de la salud mental están más que reconocidas en las investigacionesempíricas, de manera que el desempleo, la pérdida de ingresos, los problemas con lavivienda y la desigualdad social reducen el bienestar mental, y en este sentido,continúan, los impactos de la recesión y de las políticas de austeridad en Europa hansido catastróficos, entro otros, por el aumento de la tasa de suicidios.

36 En esta línea advierten Gool y Pearson (2014: 28), al señalar que cada vez existen másevidencias de que las crisis económicas están fuertemente relacionadas con una peorsalud, sobre todo en el área de la salud mental y en algunas causas de mortalidad.Además, el desempleo tiene efectos que se propagan más allá de los propiostrabajadores desempleados, aumentando la inseguridad entre su familia y sucomunidad (Gili et al., 2012: 104).

37 Asimismo, a diferencia de la salud física, los efectos de la recesión económica en lasalud mental se manifiestan a corto plazo, de modo que el desempleo, la precariedadlaboral o el deterioro de los salarios acontecidos durante estos años de crisis, hanafectado a la salud mental de los ciudadanos, aumentando también sus exigenciascognitivas y emocionales relacionadas con el trabajo (Antunes, 2015: 272).

38 En el caso de España, entre los años 2006 y 2010, las personas afectadas por problemasmentales aumentaron significativamente (Sequeira et al., 2015: 72). Además, entre lospredictores de una peor salud mental se encuentra el hecho de ser mujer, y convienerecordar que en España el mayor impacto de la crisis se ha dado entre las mujeres, conmayores tasas de desempleo, mayores tasas de empleo parcial, precariedad y menoresingresos (Tamayo-Fonseca et al., 2018: 11). De modo que el impacto de la crisiseconómica sobre las mujeres se ha visto multiplicado.


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Reflexiones finales y conclusiones

39 Como recuerdan Ruiz y Pardo (2005: 32), “la salud se ha convertido en un bien social […]y se percibe como uno de los determinantes del desarrollo personal y de la felicidad delindividuo”. Tanto es así que los datos de la OCDE (2017) apuntan a que entre los años2011 y 2017 en España y Portugal es el elemento que más preocupa para tener unabuena vida.

40 En este sentido, según Fernández-Mayoralas y Rojo (2005: 122), la calidad de vida es loque el individuo determina que es importante para su propia vida, de manera que setrata de una percepción individual, pero influenciada por múltiples factores, como lasexperiencias, las expectativas y las circunstancias personales y sociales, y dado queestos factores pueden variar, la idea de calidad de vida no es estática, sino dinámica.

41 Parece evidente entonces que para valorar la calidad de vida es necesario un enfoquedoble y complementario, desde el punto de vista objetivo de “las condiciones ycircunstancias objetivas en que se desarrolla la vida de los individuos y grupos sociales,y la evaluación subjetiva que los sujetos realizan sobre ellas” (ibidem: 131). Es decir,resulta imprescindible aunar los análisis sobre las condiciones (objetivas) de vida de laspersonas, con la satisfacción (subjetiva) que experimentan en relación con esascondiciones de vida, tal y como señalan autores como González-Cabanach et al. (2010: 6).

42 Pero no hay que olvidar, y así lo resumen González-Cabanach et al. (ibidem: 7-9), quecuando se repasan los distintos enfoques metodológicos en relación con el análisis de lacalidad de vida, existe un componente social fundamental incorporado en todas lasaproximaciones teóricas y metodológicas, que incluye componentes sociales como elsistema económico, las tendencias políticas, el bienestar material, la inclusión social, elestado financiero, el empleo o los ingresos.

43 Los datos son claros al respecto: la crisis ha impactado de lleno en todos y cada uno deestos componentes, tanto en España como en Portugal, y mucho de ellos están lejos dehaber mejorado los niveles anteriores a la crisis (véase Tabla II). TABLA II – Indicadores sociales de riesgo para la salud. Evolución comparada: UE 28, España yPortugal (2008-2016)

Evolución 2008-2013 Evolución 2014-2016 Sentido evolución

UE28

España PortugalUE28

España PortugalUE28

España Portugal

Tasa de paro 9,9 22,0 13,6 9,4 22,1 12,6 + = +

Paro larga duración 3,9 7,8 6,1 4,5 11,3 7,3 - - -

Riesgo de pobreza yexclusión social

24,4 26,0 25,6 23,9 28,6 26,4 + - -

Privación materialsevera

18,9 14,3 22,5 17,1 16,5 22,3 + - =


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Índice de Gini 30,6 33,5 34,6 30,9 34,6 34,1 = - +

Nota: En “Sentido evolución” (+) significa mejor situación; (=) situación similar; y (-) peor situación.Fuente: elaboración propia a partir de Eurostat (2016).

44 En este sentido, en el caso de España, alguna de las recomendaciones derivadas de losresultados de Oliva et al. (2018: 211) señalan los determinantes sociales como clavespara las políticas públicas en materia de salud, porque existe un empeoramiento de losindicadores generales de riesgo social, y los efectos están siendo heterogéneos entredistintos grupos de población, como las personas más jóvenes, las personasdesempleadas o aquellas que tienen empleos más precarios. El informe hace hincapiéen un aspecto crucial entre los determinantes sociales de riesgo para la salud, como esel ámbito laboral, que, según sus evidencias, se revela como el marco donde secronifican los riesgos para la salud.

45 Según Sequeira et al. (2015: 74-75), el impacto de la crisis económica en la salud mentalse transfiere a través de cuatro mecanismos: a) el impacto en el nivel de acceso a loscuidados dada la menor financiación pública; b) el aumento de situaciones de pobreza,exclusión social, disminución de la calidad de vida y la satisfacción, con el consecuenteaumento de depresiones y suicidios; c) el impacto en los cuidados familiares, que dadolos menores ingresos, recaen en familiares no cualificados, lo que se traduce en unasobre carga de trabajo para estas personas; y d) el impacto económico y social, lo queinterfiere en la productividad y el absentismo.

46 En este sentido, una de las lecciones de la crisis es que la economía, el empleo y suscondicionantes, no solo tienen consecuencias económicas o laborales, sino que tienenefectos directos sobre la salud en general, y sobre la salud mental en particular, de ahíla necesidad de “introducir la salud en todas las políticas y fomentar políticasintersectoriales” (Cortès-Franch y López-Valcárcel, 2014: 5). Y en ese diseño de laspolíticas públicas, los responsables deben ser conscientes de la importancia de invertiren salud para impulsar la economía (Quaglio et al., 2013: 16).

47 Como apuntan Quaglio et al. (ibidem: 17), los cuidados sanitarios se presentan a menudoy exclusivamente como una fuente de gasto y de consumo de recursos, pero se trata deun sector que contribuye de manera significativa al crecimiento de la economía, dadoque representa el 9 % del PIB en la UE 28 y el 10 % del empleo. Y continúan subrayandoque los impactos negativos de las crisis sobre la salud pueden evitarse con unaprotección social adecuada, con la promoción de la sanidad y con una provisiónadicional de cuidados sanitarios. Así mismo, más allá de las estrategias generales,laborales y sociales que deban implantarse, es importante desarrollar políticasespecíficas para aquellos colectivos más expuestos a los efectos de las crisis económicasen cuanto a salud mental se refiere (Córdoba-Doña et al., 2016: 10), porque tener lacapacidad de proveer de tratamientos adecuados y efectivos no solo tiene beneficiospara la salud de los individuos, sino también para la economía, en relación con unasmejores perspectivas de empleo, tan importantes en mercado de trabajo como elespañol, pero también de mejores salarios y mayores incrementos de productividad(Gool y Pearson, 2014: 28).

48 Como señalan Cortès-Franch y López-Valcárcel (2014: 2), el impacto de las crisis económicas en la salud y en las desigualdades en saluddepende de distintos factores, como el momento histórico, las características


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culturales del país, el desarrollo previo de las políticas sociales y, sobre todo, laspolíticas desarrolladas por los gobiernos para superar esta situación.

49 En este sentido, resulta necesario implementar políticas sociales contracíclicas queprotejan a los que se ven más afectados por las crisis económicas para mantener susniveles de gasto sanitario, dado que es evidente que en tiempos de recesión económicalas familias reducen sus gastos en cuidados de la salud, de manera que aquellos conmenores niveles de ingreso se ven más abocados a esta situación, y son precisamentelos que más necesitan políticas públicas que les protejan cuando el desempleo aumentay los ingresos de las familias disminuyen (Gool y Pearson, 2014: 29). Además, convienetener en cuenta que

estamos ante una mayor permeabilidad en las barreras entre los diferentes nivelesde vulnerabilidad según los niveles socioeconómicos, que pasan a ser una de lasclaves que permiten distinguir entre aquellas subpoblaciones susceptibles de ver susalud afectada por el contexto económico y aquellas subpoblaciones menosafectadas. (Spijker y Gumá, 2018: 668)

50 Ante estas evidencias, “las respuestas políticas sobre cómo gestionar las crisis son elaspecto determinante para mitigar o magnificar los impactos negativos en la salud y enlas desigualdades en salud” (Cortès-Franch y López-Valcárcel, 2014: 5). No debemospermitir que la desigualdad en el acceso a la salud acentúe aún más las desigualdadesen la Unión Europea, ni que represente una nueva fuente de discriminación entre suspaíses miembros (Quaglio et al., 2013: 17).

Se impone el convencimiento de la UE no funciona: ni supo afrontar la GranRecesión respondiendo a las necesidades de la ciudadanía ni está sabiendo abordarlos desafíos que tenemos planteados […] El verdadero y más amenazante de losdéficits no es el relativo a las cuentas públicas, sino aquel que expresa la falta delegitimidad democrática. (Álvarez Cantalapiedra, 2019: 5)

51 Y en este sentido, urge entender la opinión pública respecto a los cuidados sanitarios,porque el papel principal del Estado de Bienestar es proteger a la ciudadanía,especialmente a aquellos más vulnerables, de riegos e incertidumbres, y porque,además, la sanidad pública es un elemento que legitima el papel y el desarrollo delpropio Estado de Bienestar. La extensión de opiniones negativas al respecto puedederivar en un cuestionamiento de la legitimidad del Estado de Bienestar (Popic et al.,2019: 743), y por tanto debilita las posibilidades de desarrollo futuro, y no solo ensanidad. La gobernanza económica europea debe sustituirse por una “gobernanzarealmente democrática” (Álvarez Cantalapiedra, 2019: 10), que recupere la dimensiónsocial del proyecto europeo como núcleo central de la política en todas susdimensiones.

52 Los actuales retos económicos y sociales a los que se enfrentan España y Portugal, perola Unión Europea en general, en relación con la redefinición de sus políticas sociales,económicas y laborales debe procurar integrar una concepción más amplia delbienestar individual y social de los países, incorporando indicadores objetivos ysubjetivos tanto en el diseño de las políticas como en su evaluación posterior.Propuestas como la de Feigl (2017: 3) sobre el uso de un nuevo cuadro de indicadores yuna serie de reformas de gobernabilidad permitiría una política mucho más coherentecentrada en el objetivo general de bienestar, en línea entre otras iniciativas, como losObjetivos de Desarrollo Sostenible o la iniciativa Más allá del PIB de la propia ComisiónEuropea.


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53 Se trata de pensar una política económica orientada hacia el bienestar, la sostenibilidady la convergencia en Europa, que se centre fundamentalmente en la mejora de lacalidad de vida, el empleo decente y una justa distribución del bienestar material,acompañadas de una actividad estable del sector público, la sostenibilidad ambiental yunas relaciones económicas estables y equilibradas para las sociedades, pero tambiénpara los individuos.

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Spijker, Jerone; Gumá, Jordi (2018), “El efecto de la crisis económica sobre la salud en Españasegún el nivel educativo y la relación con la actividad: ¿importa también la duración de lacrisis?”, Salud Colectiva, 14(4), 655-670.

Tamayo-Fonseca, Nayara; Nolasco, Andreu; Moncho, Joaquín; Barona, Carmen; Irles, MaríaÁngeles; Más, Rosa; Girón, Manuel; Gómez-Beneyto, Manuel; Pereyra-Zamora, Pamela (2018),“Contribution of the Economic Crisis to the Risk Increase of Poor Mental Health in a Region in


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NOTAS1. El Índice para una vida mejor es una aplicación web interactiva, disponible en http://www.oecdbetterlifeindex.org/es/, que permite a los usuarios comparar sus propias valoracionessobre el bienestar entre los países de la OCDE y terceros países, sobre la base de once indicadoresde bienestar que incluyen los siguientes: vivienda, ingresos, empleo, comunidad, educación,medio ambiente, compromiso cívico, salud, satisfacción con la vida, seguridad y balance vida-trabajo. 2. Statistics Explained – SDG 3 Good Health and Well-Being: Ensure Healthy Lives and PromoteWell-Being for All at All Ages. Consultado el 11.10.2018, en https://ec.europa.eu/eurostat/statistics-explained/index.php/SDG_3_-_Good_Health_and_well-being.

RESÚMENESTanto el impacto de la crisis desatada en 2008 como su gestión a través de las políticas deausteridad han tenido un claro efecto en los servicios sanitarios y en la salud, tanto en Españacomo en Portugal. En este artículo se analizan algunas evidencias de este impacto desde unadoble perspectiva: los indicadores objetivos relativos a la sanidad y los servicios sanitarios enambos países, y los indicadores subjetivos sobre calidad de vida relacionada con la sanidad y lasalud, y la satisfacción de los individuos con los servicios sanitarios. Los datos muestran que, sibien los indicadores objetivos han mejorado una vez superada la crisis, no ocurre los mismo con


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https://www.mdpi.com/1660-4601/15/11/2517

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https://onlinelibrary.wiley.com/doi/pdf/10.1002/hec.918

http://www.oecdbetterlifeindex.org/es/




https://ec.europa.eu/eurostat/statistics-explained/index.php/SDG_3_-_Good_Health_and_well-being




los indicadores subjetivos, entre otras razones, porque los determinantes sociales de la salud aúnestán lejos de superar la crisis.

Both the impact of the crisis unleashed in 2008 and its management through austerity policieshave had a clear effect on health and health services both in Spain and in Portugal. Someevidences of this impact are analyzed in this article from a dual perspective: the objectiveindicators related to health and health services in both countries, and the subjective indicatorson quality of life related to health and health services, including the users’ satisfaction with thehealth services. The data shows that, although the objective indicators have improved once thecrisis was overcome, that was not the case with the subjective indicators. This happens, amongother reasons, because the social determinants of health are still far from overcoming the crisis.

ÍNDICE

Keywords: austerity, crisis, health, quality of life, satisfactionPalabras claves: austeridad, calidad de vida, crisis, salud, satisfacción

AUTOR

ELENA CACHÓN GONZÁLEZ

Universidad a Distancia de MadridVía de Servicio A-6, 15, 28400 Collado Villalba, Madrid, Españ[email protected]


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Contexto económico ydeterminantes sociales de laaccidentabilidad laboral en el sur deEuropa. Los casos portugués yespañolEconomic Context and Social Determinants of Occupational Accidentability inSouthern Europe. The Portuguese and Spanish Cases

Raúl Payá Castiblanque

NOTA DEL EDITOR

Recibido: 02.01.2019Aceptación comunicada: 29.05.2019

Introducción

1 Con la caída de Lehman Brothers en 2008 se iniciaba una década de crisis financiera yestancamiento económico a nivel global (a Gran Recesión), que ha sido utilizada por lasinstituciones internacionales de orientación neoliberal (la Troika formada por laComisión Europea, el Banco Central y el Fondo Monetario Internacional) para imponerpolíticas de austeridad económica y desregulación social orientadas a la transformaciónradical de los mercados de trabajo y de las relaciones laborales (la Gran Agresión),provocando un notable incremento de la desigualdad y el debilitamiento de lasestructuras y prestaciones del Estado de Bienestar (la Gran Regresión) (Lehndorff,2015).


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2 En los Estados del sur de Europa, la Troika impuso duros programas de desregulación yflexibilización de las condiciones de trabajo con objeto de hacer frente a la deudapública y mejorar, supuestamente, el dinamismo y posicionamiento de los mercadosnacionales en una economía global. La reforma del Código do Trabalho en Portugal (Lein.º 23/2012, de 25 de junho) y la del Estatuto de los Trabajadores en España (RealDecreto-ley 3/2012, de 10 de febrero) fomentaron un espectacular crecimiento deltrabajo atípico (contratación temporal, de duración determinada y trabajo nodeclarado), la intensificación del trabajo (aceleración de los tiempos de producción,ampliación de la jornada laboral y de las horas extraordinarias), la devaluación salarial,la flexibilización de los expedientes de regulación de empleo y, finalmente, eldebilitamiento de las instituciones y recursos del poder sindical (Costa, 2012; Leite et al.,2014; Alós et al., 2017).

3 A los efectos de nuestra investigación, cabe señalar que la precariedad laboral impuestaopera negativamente en dos sentidos. En primer lugar, pone en peligro el Estado deBienestar, en la medida que el sistema de protección (asistencia sanitaria y prestacionessociales) se financia en la mayoría de los países europeos a través de las aportaciones delos/las empresarios/as y trabajadores/as por el rendimiento del trabajo. Enconsecuencia, las medidas de austeridad reducen los ingresos estatales, que dependenen gran medida de políticas de pleno empleo y salarios decentes, provocando fuertesrecortes en gasto público sanitario y otros de índole social (Benavides et al., 2018).

4 En segundo lugar, dichas políticas impactan negativamente en los estándares de saludlaboral, en la medida que la contratación temporal opera como un elemento diferencialen el aumento de los accidentes de trabajo (Boix et al., 1997; Benavides et al., 2006),como lo hace también, la intensificación del trabajo (Askenazy, 2005). Por su parte, lasaltas tasas de desempleo erosionan el poder de negociación de los trabajadores y susorganizaciones de clase, retroalimentando la espiral de desregulación y deterioro de lascondiciones de trabajo y salud laboral (Arocena Garro y Núñez Aldaz, 2005),consideradas, en el discurso legitimador del capitalismo neoliberal, como una especiede “peaje” o “daño colateral” para la salida de la crisis económica (Terrés et al., 2004).

5 En este punto, los datos oficiales registrados por Eurostat sobre la distribución yevolución reciente del índice de incidencia por accidentes de trabajo estandarizados(número de accidentes por cada 100 000 personas trabajadoras con cuatro o más días debaja laboral) permiten constatar que son los países periféricos del sur de Europa –salvoel caso de Italia que por sus condiciones particulares que analizaremos posteriormente–, los que presentan una mayor accidentabilidad (ver Gráfica I), doblando incluso lamedia comunitaria que registra, además, una evolución positiva.


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GRÁFICA I – Índice de incidencia de accidentes de trabajo en los países del Sur de Europa(2004-2016)

Nota: No se analiza el caso de Grecia dado que, según Eurostat, no contabiliza losempleados que no están asegurados por la Social Insurance Foundation (IKA, en elacrónimo griego) y que suponen alrededor del 60-70 % de los trabajadores, por lo que losdatos resultantes no acreditan la fiabilidad y homogeneidad necesarias para suutilización en estudios comparados.Fuente: Elaboración propia a partir de Eurostat (s. d.).

6 Así las cosas, la hipótesis que nos planteamos como eje vertebrador de nuestrainvestigación es que el efecto combinado de la agresiva desregulación del mercado detrabajo y de las relaciones laborales en los países europeos periféricos, con elconsiguiente aumento de la precariedad contractual, debilitamiento de las institucionesde participación y representación de los/as trabajadores/as y la reducción de lacobertura y eficacia de la negociación colectiva, estaría operando como factordeterminante de los elevados índices de incidencia de la siniestralidad laboral, así comode su evolución reciente.

7 A tal efecto analizaremos, en primer lugar, la evolución y distribución de los principalesindicadores de precariedad laboral1 (contratación temporal, índices de rotación,segmentación) y sus efectos sobre los accidentes de trabajo para centrarnos,posteriormente, en evaluar el impacto y límites de la intervención sindical (presencia,audiencia e influencia) sobre la calidad del empleo y la salud laboral de los trabajadores(Beneyto, 2017).


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1. Crisis económica, precariedad laboral yaccidentabilidad

8 El modelo de crecimiento económico de los países del sur de Europa se centra, en granmedida, en sectores que aportan bajo valor añadido y un uso intensivo de mano de obrapoco cualificada, lo que puede explicar el impacto diferencial que ha tenido sobre losindicadores sociolaborales tanto en términos de precariedad como de salud laboral(Santos et al., 2010).

GRÁFICA II – Tasa de temporalidad y de desempleo en los países del sur de Europa (2008-2016)

Fuente: Elaboración propia a partir de Eurostat.Eurostat. Temporary employees as percentage of the total number of employees, by sex, age andcitizenship (%). Consultado el 16.12.2018, en https://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=lfsa_etpgan&lang=en; Eurostat. Unemployment rates by sex, age and citizenship (%).Consultado el 16.12.2018 de https://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=lfsa_urgan&lang=en.

9 En efecto, tal y como podemos observar en la Gráfica II, mientras que Italia y Francia seencuentra en torno a la media de la Unión Europea (UE), las medidas de flexibilizaciónllevadas a cabo por las reformas laborales de 2012 en España, y en menor medidaPortugal, han derivado en elevadas tasas de temporalidad y desempleo, llegando adoblar la media europea en el caso español (Alós et al., 2017), por lo que centraremos enambos países nuestro análisis del impacto de dichas medidas sobre los accidentes detrabajo, según características de la empresa (sector de actividad y tamaño del centro detrabajo) y de los trabajadores (sexo, edad, situación profesional, tipo de contrato yantigüedad) en el periodo comprendido entre el inicio de las reformas laborales (2012)y el de los últimos datos disponibles en materia de siniestralidad (2016).

10 A tal efecto, se han realizado diversas operaciones estadísticas, transformando, enprimer lugar, los datos absolutos de los accidentes totales en índices de incidencia (n.ºde personas accidentadas/n.º de personas expuestas por cada 100 000 trabajadores/as)con objeto de garantizar la comparabilidad de los datos resultantes. Para efectuar lasoperaciones, se han utilizado los datos correspondientes al número de accidentes delGabinete de Estratégia e Planeamento (GEP/MTSSS)2 para Portugal y las estadísticas deaccidentes de trabajo del Anuario de Estadísticas del Ministerio de Empleo y Seguridad Social3 para el caso español. El universo de control, es decir, el número – total de personasexpuestas, se ha extraído de la Encuesta de Población Activa (EPA)4 de cada país.

11 Para analizar las probabilidades de sufrir accidentes de trabajo por parte de losdiferentes colectivos, se ha procedido al cálculo del riesgo relativo (en adelante RR), conun intervalo de confianza del 95 % (en adelante IC95 %), comúnmente utilizado en


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https://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=lfsa_urgan&lang=en




estudios epidemiológicos de salud pública, lo que nos proporciona información sobre elgrado de asociación estadística de sufrir accidentes de trabajo entre un colectivorespecto a un grupo de control. De esta manera si el RR resultante es superior a 1, elcolectivo correspondiente tendrá mayor probabilidad de sufrir un accidente de trabajo,mientras que si es inferior la probabilidad de registrar accidentes será menor. El IC95 %,nos proporciona información sobre si la relación es estadísticamente significativa en unnivel de confianza del 95 %. En este sentido el RR de sufrir accidentes de un grupo depersonas trabajadoras frente a otro colectivo de control será significativa cuando entreel IC inferior y superior no se encuentra comprendido el valor número uno. 1.1. Accidentes de trabajo según características de la empresa

12 La Tabla I registra las desigualdades intersectoriales de los índices de incidencia poraccidentes de trabajo, tanto en Portugal como en España, en la medida que el sectorsecundario, y más concretamente el de la construcción para el caso español, doblanprácticamente las respectivas medias nacionales, siendo máximas las diferencias en2016 (RR= 2,07; IC95 % 1,99-2,15).

13 Tales resultados no hacen sino confirmar la hipótesis de estudios anteriores, en lamedida que en los países mediterráneos la especialización productiva en sectoresprecarios e intensivos en mano de obra constituye un factor explicativo de los elevadosíndices de incidencia de accidentes de trabajo (Santos et al., 2010; Payá y Beneyto,2018a). La sectorialización del riesgo en la construcción y la industria manufacturera(Lima, 2002), no solo tendría que ver con aspectos meramente técnicos, sino tambiéncon factores sociales y tradiciones culturales en la gestión de la fuerza de trabajo(deslocalización productiva, alteración constante de las condiciones de trabajo,concentrado mayoritariamente en pequeñas empresas, con escasa o incluso nularegulación legal y cualificación profesional) (Lima, 2004: 5).

14 Por lo que refiere al tamaño de los centros de trabajo, los resultados obtenidos,muestran cómo las empresas de entre 1 a 9 trabajadores/as en Portugal, tienen mayorprobabilidad de sufrir accidentes de trabajo, presentando las máximas diferencias en2014 (RR= 1,28; IC95 % 1,23-1,33), mientras que en España se producen más accidentesen los centros de trabajo de entre 10 a 49 trabajadores/as (RR= 1,28; IC95 % 1,22-1,34;para el año 2012). Por contra, las personas ocupadas en empresas más grandes tienenuna menor probabilidad de sufrir accidentes de trabajo, tanto en España (RR= 0,83; IC95% 0,79-0,88, en 2016) como en Portugal (RR= 0,91; IC95 % 0,87-0,95, en 2016). Sinembargo, las empresas más pequeñas (de 1 a 9 personas) en España se encuentran pordebajo de la media, lo que podría ser explicado por la infranotificación de accidentes detrabajo derivada de la débil o inexistente representación sindical que luche por lanotificación y registro de los accidentes de trabajo (Eaton y Nocerino, 2000).

15 Estudios previos han identificado una combinación de factores determinantes quevendrían a explicar la mayor siniestralidad laboral en las pymes, que presentanmenores índices de gestión preventiva (Walters, 2004: 171; Naroki, 1997: 163), enfunción tanto de variables cuantitativas –falta de recursos humanos y materiales– comocualitativa –cultura familiar, patriarcal y autoritaria– y de representación (Alós et al.,2013: 1073-1075) que limitan la capacidad de defensa y reivindicación de sustrabajadores (Lima, 2015: 195).


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16 En definitiva, la especialización productiva en sectores intensivos en mano de obra y lafragmentación empresarial, derivadas de la creciente dinámica de las economíaglobales hacia la subcontratación a empresas cada vez más pequeñas,5 y con peorescondiciones de trabajo, operan como factores determinantes de los índices deaccidentes de trabajo, especialmente en los países del sur de Europa (Naroki, 1997;Monjardino et al., 2017). TABLA I – Índice de Incidencia de accidentes totales y Riesgo Relativo por sector de actividad ytamaño de empresa en Portugal y España (2012-2016)

AñoPortugal España

II* RR** (95 %)*** II* RR** (95 %)***

Total

2012 4.258,1 1 2.948,9 1

2013 4.415,5 1 3.009,2 1

2014 4.523,8 1 3.111,3 1

2015 4.582,8 1 3.252,0 1

2016 4.507,2 1 3.364,0 1

Sector de Actividad

Agrario

2012 1.188,2 0,29 (0,27-0,31) 4.339,2 1,45 (1,39-1,52)

2013 1.448,7 0,34 (0,32-0,36) 4.599,7 1,51 (1,44-1,57)

2014 2.211,0 0,50 (0,48-0,53) 4.768,8 1,51 (1,44-1,58)

2015 2.545,1 0,57 (0,54-0,59) 5.167,6 1,56 (1,49-1,63)

2016 2.478,6 0,56 (0,55-0,57) 5.143,4 1,50 (1,44-1,57)

Industria

[Sector Secundario para Portugal]

2012 7.339,3 1,67 (1,61-1,74) 4.652,0 1,55 (1,48-1,62)

2013 7.823,7 1,72 (1,66-1,78) 4.590,7 1,50 (1,44-1,57)

2014 7.956,5 1,70 (1,64-1,73) 4.781,2 1,51 (1,45-1,58)

2015 7.626,3 1,62 (1,56-1,68) 5.087,5 1,54 (1,47-1,60)

2016 7.121,7 1,54 (1,49-1,60) 5.290,8 1,54 (1,48-1,61)

Construcción

2012 - - 6.296,9 2,07 (1,98-2,16)

2013 - - 6.024,1 1,94 (1,86-2,03)

2014 - - 6.314,7 1,97 (1,89-2,05)

2015 - - 6.794,5 2,02 (1,94-2,10)


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2016 - - 7.217,2 2,07 (1,99-2,15)

Servicios

2012 3.565,6 0,84 (0,81-0,84) 2.305,6 0,79 (0,17-0,25

2013 3.645,8 0,83 (0,80-0,87) 2.433,3 0,81 (0,77-0,86)

2014 3.584,9 0,80 (0,77-0,83) 2.513,7 0,81 (0,77-0,86)

2015 3.696,8 0,81 (0,78-0,85) 2.591,7 0,80 (0,76-0,84)

2016 3.777,7 0,84 (0,81-0,88) 2.677,9 0,80 (0,76-0,84)

Tamaño de centro de trabajo

1 a 9 trabajadores/as

2012 5.030,7 1,17 (1,13-1,22) 2.183,1 0,75 (0,71-0,79)

2013 5.500,1 1,23 (1,19-1,28) 2.118,2 0,71 (0,67-0,75)

2014 5.859,8 1,28 (1,23-1,33) 2.210,7 0,72 (0,68-0,76)

2015 5.506,6 1,19 (1,15-1,24) 2.280,5 0,71 (0,67-0,75)

2016 5.183,8 1,14 (1,10-1,19) 2.320,7 0,70 (0,66-0,73)

10 a 49 trabajadores/as

2012 4.989,4 1,16 (1,12-1,21) 3.799,3 1,28 (1,22-1,34)

2013 4.453,8 1,01 (0,97-1,05) 3.644,3 1,20 (1,15-1,26)

2014 4.563,3 1,01 (0,97-1,05) 3.746,8 1,20 (1,14-1,25)

2015 4.318,4 0,94 (0,91-0,98) 3.962,3 1,21 (1,16-1,27)

2016 4.296,3 0,96 (0,92-1,00) 4.147,9 1,22 (1,17-1,28)

50 o más trabajadores/as

2012 4.210,5 0,99 (0,95-1,03) 2.459,5 0,84 (0,79-0,88)

2013 3.859,0 0,88 (0,84-0,92) 2.441,0 0,82 (0,77-0,85)

2014 3.890,2 0,87 (0,83-0,90) 2.497,0 0,81 (0,77-0,85)

2015 3.938,3 0,86 (0,83-0,90) 2.693,1 0,83 (0,79-0,88)

2016 4.077,6 0,91 (0,87-0,95) 2.790,4 0,83 (0,79-0,88)

* II= índice de incidencia de accidentes totales.** RR= riesgo relativo por sector de actividad o tamaño de empresa respecto a los índices deincidencia totales de cada país correspondiente a cada año.*** IC95 %= Intervalo de confianza del riesgo relativo del 95 %.Fuente: (GEP/MTSSS) de Portugal, Anuario de Estadísticas del Ministerio de Empleo y Seguridad Social deEspaña y EPA de ambos países. Cálculos y elaboración propia.


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1.2. Accidentes de trabajo según características de los/astrabajadores/as

17 Si analizamos los índices de incidencia de los accidentes de trabajo por sexo (Tabla II) sepuede observar cómo los hombres presentan, en ambos países, el doble deprobabilidades de sufrir accidentes de trabajo que las mujeres (RR= 2,00; 1,92-2,09 y RR=2,03; 1,93-2,13; respectivamente para el año 2016). Ahora bien, estas desigualdades ensalud laboral puestas de manifiesto por las estadísticas oficiales podrían estarinvisibilizando enfermedades no registradas que afectan con mayor prevalencia a lasmujeres trabajadoras.

TABLA II – Índice de Incidencia de accidentes totales y Riesgo Relativo por sexo en Portugal yEspaña (2012-2016)

AñoPortugal

II* Hombres II* Mujeres RR** (95 %)***

2012 5.694,0 2.712,2 2,04 (1,95-2,13)

2013 5.894,2 3.155,2 1,84 (1,77-1,92)

2014 6.200,9 2.739,4 2,19 (2,10-2,29)

2015 6.183,2 2.895,7 2,07 (1,98-2,16)

2016 6.020,2 2.915,0 2,00 (1,92-2,09)

España

2012 2.982,6 1.815,0 1,62 (1,53-1,72)

2013 3.968,6 1.963,4 1,98 (1,88-2,09)

2014 4.095,9 2.039,1 1,97 (1,87-2,07)

2015 4.313,6 2.088,9 2,02 (1,92-2,13)

2016 4.466,1 2.155,5 2,03 (1,93-2,13)

* II= índice de incidencia de accidentes totales.** RR= riesgo relativo de los hombres respecto a las mujeres en cada país y año.*** IC95 %= Intervalo de confianza del riesgo relativo del 95 %.Fuente: (GEP/MTSSS) de Portugal, Anuario de Estadísticas del Ministerio de Empleo y Seguridad Social deEspaña y EPA de ambos países. Cálculos y elaboración propia.

18 Las políticas de desregulación y precarización de las condiciones de empleo y trabajoimpuestas han derivado en un aumento de las patologías psicosociales (estrés,depresión, nerviosismo, problemas de sueño, etc.) (EU-OSHA, 2010). Diferentesinvestigaciones han puesto de manifiesto que el efecto combinado de la división sexualdel trabajo, los roles familiares y las peores condiciones de trabajo hacen que lasmujeres trabajadoras sufran con mayor prevalencia estos riesgos psicosociales


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(Artazcoz et al., 2011; Arcas et al., 2013). Sin embargo, estas patologías no se encuentranreconocidas legalmente como enfermedades profesionales en la mayoría de los paísesde la UE, estimándose para el caso español que “si se añadieran a las bajas porenfermedades profesionales reconocidas los aproximadamente 400.000 casos anuales debajas por contingencia común provocadas por causas psicológicas o psiquiátricas, lacifra total aumentaría en casi un 40 %” (Sánchez y Conde, 2008: 287), lo que prodríallegar a suponer una discriminación indirecta hacia las mujeres trabajadores en lamedida que sufren con mayor intensidad estas patologías laborales.

19 Por lo que refiere a la edad de las personas trabajadoras también se constatandesigualdades en materia de salud laboral (Lima, 2015: 191). Mientras que los/as másjóvenes entre 15 y 24 años presentan mayor probabilidad de sufrir accidentes detrabajo que la media nacional, tanto en Portugal (RR= 1,54; IC95 % 1,49-1,60; en 2016)como en España (RR= 1,17; IC95 % 1,12-1,23; en 2016), las personas de mayor edad (55 omás años) registran tasas de accidentes inferiores a la media (RR= 0,73; IC95 % 0,70-0,76;RR= 0,64; IC95 % 0,61-0,68; respectivamente).

20 Tales diferencias se explicarían no tanto por factores sectoriales (mayor o menorconcentración de trabajadores en actividades de riesgo) sino por los de carácterestructural (desigual impacto de la crisis y el paro) y contractual (precariedad,temporalidad). Respecto del primer caso, la encuesta de población activa españolapermite identificar que la tasa de empleo en la construcción para trabajadores/as de 50a 64 años fue del 5,8 % en 2012 y del 6 % en 2016, mientras que para los de 16 a 24 añosfue del 5,4 % al 3,1 % respectivamente; diferencia que se mantiene en la industriamanufacturera con tasas de ocupación del 12,5 % en 2012 y del 11,5 % en 2016 para los/las más mayores y del 9,67 % al 10,6 % respectivamente, para los/las más jóvenes.

21 En cuanto al desigual impacto de la crisis económica sobre el desempleo y laprecariedad contractual, la encuesta de población activa de ambos países sitúan el nivelde desempleo de los/las jóvenes (34,2 % en 2012 y 26,16 % en 2016 para trabajadores/asde 20 a 24 años en Portugal y del 48,8 % al 41,4 % respectivamente, en España) muy porencima de las personas trabajadoras de mayor edad (12,7 % en 2012 y 11,2 % en 2016,para los/as trabajadores/as de 55 a 64 años en Portugal, y de un 17,4 % al 19,7 %respectivamente, para España), siendo aun mayor la diferencia en materia deprecariedad, con tasas de temporalidad del 52,6 % en 2012 y del 62,8 % en 2016 para los/as trabajadores/as de 15 a 24 años en Portugal, y del 56,8 % al 67,7 % respectivamente,para el caso español, mientras que para los 55 a 64 años fue del 6,7 % en 2012 en ambospaíses y del 7,4 % en 2016 para Portugal y del 8,8 % en España.

22 Así pues, la débil posición de las personas más jóvenes en el mercado de trabajo haceque se vean obligados a aceptar condiciones precarias y, en consecuencia, susceptiblesde sufrir más accidentes de trabajo (ver Tabla III) (Terrés et al., 2004; Arocena Garro yNúñez Aldaz, 2005). TABLA III – Índice de Incidencia de accidentes totales y Riesgo Relativo por edad en Portugal yEspaña (2012-2016)

Edad AñoPortugal España

II* RR** (95 %)*** II* RR** (95 %)***


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De 15 a 24 años

De 16 a 24 años en España

2012 6.772,5 1,55 (150-1,61) 3.581,8 1,21 (1,15-1,27)

2013 6.635,8 1,47 (1,42-1,53) 3.164,7 1,05 (1,00-1,10)

2014 6.946,0 1,50 (1,45-1,56) 3.239,6 1,04 (0,99-1,09)

2015 7.281,9 1,55 (1,49-1,61) 3.529,1 1,08 (1,03-1,13)

2016 7.121,6 1,54 (1,49-1,60) 3.974,2 1,17 (1,12-1,23)

De 25 a 34 años

2012 5.009,0 1,17 (1,12-1,22) 2.602,4 0,89 (0,84-0,93)

2013 5.040,0 1,13 (1,09-1,18) 2.528,6 0,84 (0,80-0,89)

2014 5.035,9 1,11 (1,07-1,15) 2.567,0 0,83 (0,79-0,87)

2015 4.813,9 1,05 (1,01-1,09) 2.749,8 0,85 (0,81-0,89)

2016 4.804,9 1,06 (1,02-1,11) 2.853,3 0,85 (0,81-0,90)

De 35 a 44 años

2012 4.473,9 1,05 (1,01-1,09) 2.317,4 0,79 (0,75-0,83)

2013 4.550,2 1,03 (0,99-1,07) 2.321,8 0,78 (0,74-0,82)

2014 4.481,0 0,99 (0,95-1,03) 2.417,4 0,78 (0,74-0,82)

2015 4.485,8 0,98 (0,94-1,02) 2.531,7 0,78 (0,74-0,82)

2016 4.286,8 0,95 (0,91-0,99) 2.666,3 0,80 (0,76-0,84)

De 45 a 54 años

2012 4.145,1 0,97 (0,93-1,02) 2.211,8 0,76 (0,72-0,80)

2013 4.166,9 0,95 (0,91-0,99) 2.308,7 0,77 (0,73-0,81)

2014 4.416,1 0,98 (0,94-1,02) 2.351,5 0,76 (0,72-0,80)

2015 4.494,5 0,98 (0,94-1,02) 2.462,3 0,76 (0,72-0,80)

2016 4.475,5 0,99 (0,95-1,03) 2.543,9 0,76 (0,72-0,80)

55 o más años

2012 2.408,4 0,58 (0,55-0,60) 1.899,1 0,65 (0,61-0,69)

2013 2.423,3 0,56 (0,53-0,59) 2.019,8 0,68 (0,64-0,71)

2014 3.041,6 0,68 (0,65-0,71) 2.070,1 0,67 (0,64-0,71)

2015 3.280,9 0,72 (0,69-0,76) 2.077,0 0,65 (0,61-0,68)


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2016 3.244,9 0,73 (0,70-0,76) 2.136,0 0,64 (0,61-0,68)

* II= índice de incidencia de accidentes totales.** RR= riesgo relativo por tramo de edad respecto a los índices de incidencia totales de cada paíscorrespondiente a cada año.*** IC95 %= Intervalo de confianza del riesgo relativo del 95 %.Fuente: GEP/MTSSS de Portugal, Anuario de Estadísticas del Ministerio de Empleo y Seguridad Social deEspaña y EPA de ambos países. Cálculos y elaboración propia.

1.3. Accidentes de trabajo según situación profesional y tipo decontrato

23 Por lo que refiere a las desigualdades de salud entre clases sociales, los análisisestadísticos realizados sobre la erosión del Estado de Bienestar por Stuckler et al.concluyeron que “la rápida privatización masiva como estrategia de transicióneconómica fue un determinante crucial de las diferencias en las tendencias demortalidad de adultos” (Stuckler et al., 2009: 399; traducción propia). Esta situación,podría quedar también reflejada en las estadísticas de salud laboral puesto que los/astrabajadores/as por cuenta ajena en el caso portugués llegan a quintuplicar lasprobabilidades de sufrir accidentes de trabajo con respecto a los/las propietarios/as delos medios de producción (RR= 5,73; IC95 % 5,33-6,15; en 2012), siendo tambiénsignificativa dicha diferencia, aunque en menor medida, para el caso español (RR= 1,21;IC95 % 1,14-1,28; en 2012) (Tabla IV). La desregulación del mercado de trabajo españolpodría haber producido un efecto similar a la privatización de los servicios públicos desalud en la medida que la probabilidad de sufrir accidentes de trabajo entreempresarios/as y trabajadores/as aumentó desde un (RR= 1,21; IC95 % 1,14-1,28) en2012 hasta un (RR= 1,54; IC95 % 1,45-1,62) en 2016, mientras que en Portugal lasprevalencias no presentaron una tendencia temporal lineal.

TABLA IV – Índice de Incidencia de accidentes totales y Riesgo Relativo por situación profesional enPortugal y España (2012-2016)

Portugal

AñoII* Trabajador/a por CuentaAjena

II* Trabajador/a Autónomo/a y/oEmpresario/a

RR** (95%)***

2012 5.147,2 862,35,73(5,33-6,15)

2013 5.313,2 1.036,64,92(4,60-5,25)

2014 5.054,9 1.991,12,46(2,34-2,59)

2015 4.628,4 1.747,32,58(2,44-2,72)


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2016 4.866,3 1.481,13,18(3,00-3,37)

España

2012 2.764,4 2.277,31,21(1,14-1,28)

2013 2.774,2 2.241,11,23(1,17-1,30)

2014 2.840,2 2.220,51,27(1,20-1,34)

2015 3.076,1 2.025,91,50(1,42-1,59)

2016 3.099,4 1.995,61,54(1,45-1,62)

* I= índice de incidencia de accidentes totales.** RR= riesgo relativo de los/as trabajadores/as por cuenta ajena respecto a los/as autónomos/as y/oempresarios/as en cada país y año.*** IC95 %= Intervalo de confianza del riesgo relativo del 95 %.Fuente: GEP/MTSSS de Portugal, Anuario de Estadísticas del Ministerio de Empleo y Seguridad Social deEspaña y EPA de ambos países. Cálculos y elaboración propia.

24 Además de las desigualdades sociales entre capital y trabajo, las estadísticas españolaspermiten comparar las diferencias de salud laboral entre la clase trabajadora,estudiando para tal efecto las desigualdades entre trabajadores/as por cuenta ajenasegún tipo de relación contractual (Tabla V) y antigüedad en la empresa (Tabla VI).

TABLA V – Índice de Incidencia de accidentes totales y Riesgo Relativo por tipo de contrato enEspaña (2012-2016)

AñoII* Temporal II* Indefinido RR** (95 %)***

Leves

2012 3.765,1 2.363,1 1,60 (1,59-1,61)

2013 3.870,8 2.430,7 1,59 (1,58-1,61)

2014 4.176,8 2.450,8 1,71 (1,70-1,72)

2015 4.521,4 2.488,3 1,82 (1,81-1,83)

2016 4.740,5 2.541,9 1,87 (1,86-1,88)

Graves

2012 36,9 19,3 1,91 (1,78-2,05)


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2013 33,0 18,4 1,79 (1,66-1,93)

2014 35,1 17,2 2,05 (1,90-2,20)

2015 36,2 17,1 2,12 (1,97-2,27)

2016 37,9 17,1 2,18 (2,02-2,34)

Mortales

2012 4,4 2,5 1,75 (1,43-2,13)

2013 4,3 2,7 1,59 (1,30-1,95)

2014 4,9 2,5 1,93 (1,59-2,34)

2015 4,7 2,9 1,62 (1,35-1,95)

2016 4,6 2,6 1,80 (1,49-2,16)

* II= índice de incidencia de accidentes leves, graves y mortales** RR= riesgo relativo de los/as trabajadores/as con contrato temporal respecto a los/astrabajadores/as con contrato indefinido para cada año.*** IC95 %= Intervalo de confianza del riesgo relativo del 95 %.Fuente: Anuario de Estadísticas del Ministerio de Empleo y Seguridad Social y EPA. Cálculos yelaboración propia.

25 Los resultados obtenidos muestran cómo la modalidad contractual es un factordeterminante de las desigualdades en salud laboral en la medida que las personascontratadas temporalmente refieren mayor número de accidentes de trabajo, tantopara los accidentes leves (RR= 1,87; IC95 % 1,86-1,88), como los graves (RR= 2,18; IC95 %2,02-2,34) y mortales (RR= 1,80; IC95 % 1,49-2,16) para el año 2016, confirmando así losanálisis de estudios previos (Boix et al., 1997; Benavides et al., 2006), según los cuales laspolíticas neoliberales de flexibilización estarían impactando negativamente sobre lasalud de las personas trabajadoras, en especial en España y Portugal que presentaníndices de temporalidad elevados (ver Gráfica II).

TABLA VI – Índice de incidencia de accidentes totales y riesgo relativo según antigüedad en laempresa en España (2012-2016)

AñoII* menor a 1 año II* de 1 a 3 años II* más de 3 años RR** (95 %)**** RR*** (95 %)****

Leves

2012 5.277,3 2.767,8 1.691,3 1,91 (1,89-1,92) 3,22 (3,20-3,24)

2013 5.258,5 2.797,3 1.710,2 1,88 (1,86-1,90) 3,10 (3,20-3,24)

2014 5.430,0 2.773,2 1.719,3 1,96 (1,94-1,98) 3,16 (3,14-3,18)

2015 5.953,6 2.728,1 1.697,6 2,18 (2,16-2,20) 3,48 (3,46-3,50)


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2016 6.372,2 2.838,5 1.637,7 2,24 (2,23-2,26) 3,77 (3,75-3,79)

Graves

2012 48,9 21,2 15,35 2,44 (2,19-2,71) 3,37 (3,14-3,61)

2013 47,8 20,6 14,8 2,18 (1,95-2,44) 3,03 (2,81-3,26)

2014 46,4 21,1 13,0 2,19 (1,97-2,45) 3,57 (3,32-3,84)

2015 44,8 20,1 12,7 2,38 (2,14-2,65) 3,76 (3,50-4,04)

2016 51,7 21,8 14,5 2,24 (2,03-2,47) 3,93 (3,66-4,22)

Mortales

2012 6,2 2,4 1,9 2,62 (1,92-3,58) 3,29 (2,69-4,03)

2013 5,8 2,5 2,0 2,28 (1,66-3,12) 2,89 (2,35-3,55)

2014 6,6 2,6 1,9 2,55 (1,88-3,46) 3,52 (2,90-4,27)

2015 6,2 3,1 2,1 2,04 (1,54-2,69) 3,02 (2,5-3,64)

2016 5,8 3,1 1,9 1,89 (1,45-2,47) 3,09 (2,55-3,75)

* II= índice de incidencia de accidentes leves, graves y mortales.** RR= riesgo relativo de los/as trabajadores/as con menos de un año de antigüedad respecto a los/as trabajadores/as con 1 a 3 años de antigüedad en el centro de trabajo para cada año de referencia.*** RR= riesgo relativo de los/as trabajadores/as con menos de un año de antigüedad respecto a los/as trabajadores/as con 3 o más años de antigüedad en el centro de trabajo para cada año dereferencia.**** IC95 %= Intervalo de confianza del riesgo relativo del 95 %.Fuente: Anuario de Estadísticas del Ministerio de Empleo y Seguridad Social y EPA. Cálculos y elaboraciónpropia.

26 La precariedad laboral en España ha llegado a ser de tal magnitud que la contratacióntemporal es cada vez de menor duración (50,6 días de media en 2017) afectandonegativamente a la salud de las personas trabajadoras (Payá y Beneyto, 2018a). Losresultados aportados en el curso de nuestra investigación (Tabla VI) muestran unarelación inversa entre antigüedad en el centro de trabajo y accidentabilidad laboral.Los/as trabajadores/as con menos de un año de antigüedad refieren el doble deaccidentes de trabajo respecto a las personas que llevan de 1 a 3 años en la empresa,tanto para los accidentes leves (RR= 2,24; IC95 % 2,23-2,26; en 2016), como para losgraves (RR= 2,24; IC95 % 2,03-2,47, para 2016) y mortales (RR=1,89; IC95 % 1,45-2,47),llegando a triplicarse ampliamente cuando se compara con las personas con 3 o másaños de antigüedad en el centro de trabajo.

27 En conclusión, la fragilidad del mercado laboral junto a las políticas neoliberales deflexibilización han afectado gravemente a la salud de las personas trabajadorasoperando como factores determinantes de los elevados índices de accidentes laboralesen los países del sur de Europa, poniendo de manifiesto, asimismo, las múltiplesdesigualdades de salud entre clases sociales, identificadas importantes diferencias


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entre empresarios/as y asalariados/as; trabajadores/as jóvenes y mayores; temporalesy indefinidos, entre personal inexperto y los de mayor antigüedad, agravado todo ellopor la discriminación indirecta por cuestión de género.

2. Impacto y límites de la lucha sindical en saludlaboral

2.1. Impacto

28 Observado las desigualdades sociales, consideramos que la salud laboral no puede verseúnicamente desde un punto de vista tecnocrático y pretendidamente objetivo derivadode criterios prefijados por los profesionales de la prevención de riesgos laborales, sinoque debe analizarse en el marco de las relaciones asimétricas entre capital y trabajo,como una dimensión más de la lucha obrera por la mejora de sus condiciones de vida yde trabajo:

La subjetividad obrera se inscribe en el centro de la construcción de la salud que esuna movilización, consciente o no, individual o colectiva, de las potencialidades deadaptación del ser humano que le permite interactuar con su entorno de maneramás o menos eficaz en su lucha contra el sufrimiento (físico o psíquico), lasdiscapacidades, las patologías o la muerte. (Vogel, 2016a: 14)

29 Desde un punto de vista histórico, consideramos que dos hitos representan la luchaobrera en materia de seguridad y salud laboral en Europa occidental. En primer lugar,las protestas llevadas a cabo en Francia contra la céruse (albayalde o blanco de plomo)utilizada para elaborar la pintura blanca que recubría las paredes de los edificios en elsiglo XIX y principios del XX, responsable del saturnismo que padecían millones depintores. La fabricación de la céruse fue muy importante para la economía de Franciaque aglutinaba en la región de Lille la mayor parte de la producción europea. Desdemediados del siglo XIX los higienistas ya conocían que el blanco de plomo provocabagraves problemas de salud y, además, se podía sustituir fácilmente por el inofensivoóxido de zinc pero, sin embargo, era mucho más caro que la céruse, por lo que los/asgrandes patrones/as de Lille con objeto de preservar su lobby presionaron al gobierno ymedios de comunicación. El gobierno francés no se planteó prohibir de maneradefinitiva el uso de la céruse hasta la intervención de la Unión Sindical de Pintores de laConfederación General del Trabajo (CGT), que provocó grandes huelgas durante tressemanas (desde el 13 de marzo hasta el 3 de abril 1906), con el paro de doscientascuarenta empresas de pintura en Lille y la participación de más de mil pintores/as, lamayoría sindicados/as, lo que obligó a la aprobación del decreto que prohibía lautilización del plomo blanco para la fabricación de pinturas (Rainhorn, 2010).

30 El segundo hito histórico de la lucha sindical en defensa de la salud de los/astrabajadores/as fue la utilización a partir de 1830 del fósforo blanco para la elaboraciónde cerillas, responsable de la necrosis de mandíbula entre los/as obreros/as del sector.Al igual que en el caso de la céruse, entre 1845-1850, se comprobaron las elevadas tasasde mortalidad que producía el que denominaban comúnmente “veneno blanco”, y en1844, se descubrió el fósforo rojo que realizaba la misma función pero sin producirdaños para la salud. Sin embargo, los/as empresarios/as defendían el fósforo blancoporque los/las clientes lo preferían al ser más fáciles de encender, por lo que, al igualque en el caso de la céruse, presionaron y consiguieron retrasar en más de 40 años su


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prohibición. En este periodo cabe destacar las huelgas de las fábricas de cerillasBryantand May en 1888 en Londres como un movimiento clave en la lucha contra elfósforo blanco y, a su vez, muchos/as historiadores/as lo consideraron la génesis de laindependencia política de la clase obrera británica (Vogel, 2016a).

31 Estos dos episodios ponen de manifiesto que la salud laboral no es una simple variabletecnocrática objetiva, y que la lucha sindical ha tenido y tiene un papel fundamental enla defensa de los derechos a la seguridad y salud de los/as trabajadores/as en elejercicio de su actividad.

32 En la actualidad, con la aprobación de la Directiva Marco 89/391-CEE de 1989, relativa ala aplicación de medidas para promover la mejora de la seguridad y de la salud de los/as trabajadores/as en el trabajo, de carácter vinculante y de obligada transposiciónpara todos los estados pertenecientes a la UE, se reconoce, en su artículo 11.3, elderecho de los/as trabajadores/as a ser informados/as, consultados/as y a participar através de representantes especializados/as (delegados/as de prevención o comités desalud laboral, según la configuración de cada país) en la gestión de la prevención deriesgos laborales en la empresa (Benavides et al., 2018). Así pues, dicha directiva crea unnuevo órgano de representación especializado complementario e incluso superpuesto alos tradicionales de carácter general (unitaria y/o sindical) (Payá, 2014).

33 Diversas investigaciones econométricas llevadas a cabo en diferentes sistemas ycontextos de relaciones laborales, como los casos del Reino Unido (Walters y Nichols,2007), Francia (Coutrot, 2009), Italia (Instituto per il Lavoro, 2006) y España (Ollé-Espluga et al., 2015; Payá y Beneyto, 2018a), han puesto de manifiesto que en aquelloscentros de trabajo en los que hay representantes especializados/as, se lograimplementar niveles y estándares más elevados de gestión preventiva. Es decir, lasempresas que cuentan con delegados/as de prevención tienen mayor probabilidad deque se evalúen los riesgos y se planifiquen acciones de prevención para eliminarlos.Además, también ha quedado acreditado en numerosas investigaciones que la presenciade representación especializada garantiza un menor número de accidentes de trabajo(Reilly et al., 1995; Nichols et al., 2007; Robinson y Smallman, 2013). A todo ello, habríaque añadir que estudios comparados han identificado que los Estados que cuentan conuna mayor fortaleza sindical presentan una tasa de accidentes de trabajo menor(Rueda, 2004; Payá y Beneyto, 2018b). 2.2. Límites a la intervención sindical

34 Constatado el impacto positivo de la acción sindical sobre la salud laboral,consideramos que, además de los factores contextuales y modalidades contractualesque condicionan la evolución de la accidentabilidad laboral vistos en el primerapartado, las políticas neoliberales también han erosionado los recursos de podersindical de los países del sur de Europa y, por tanto, devienen como un factorexplicativo de la elevada tasa de accidentes de trabajo, por lo que nos centrarnos ahoraen su análisis y evaluación (Payá y Beneyto, 2018b; Vogel, 2016).

35 Para ello, en primer lugar, es necesario identificar los recursos de poder sindical. Eneste sentido, Gumbrell-McCormick y Hyman (2013: 30-31) enumeran y sintetizan losdistintos recursos de poder sindical que cuentan con amplio reconocimientointernacional, pudiéndose diferenciar entre: a) el poder estructural (posición y poder denegociación de los/as trabajadores/as en el mercado de trabajo); b) el poder asociativo,


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que a su vez puede dividirse en presencia (tasa de afiliación sindical) y audiencia electoral(elección democrática de representantes de los/as trabajadores/as en los centros detrabajo) (Beneyto, 2017); c) el poder institucional (acuerdos institucionales fruto de laconcertación y/o dialogo social y la negociación colectiva) y, por último, d) el podersocial o societal, que puede dividirse entre el poder discursivo y colaborativo, del que nonos ocupamos en este artículo por ocuparse de problemáticas (relaciones entresindicatos y nuevos movimientos sociales) que exceden los objetivos de nuestrainvestigación y han sido analizadas en profundidad por otros autores (Fonseca yEstanque, 2018; Beneyto, 2017). 2.2.1. Erosión del poder asociativo en salud laboral

36 En referencia al poder asociativo, la última Encuesta Europea sobre las Condiciones de Trabajo(Eurofound, 2015) informa de la tasa de presencia e influencia sindical, tanto de larepresentación general (unitaria y sindical) como de la especializada (delegados/as deprevención y comités de salud laboral). Del análisis de regresión lineal realizado sobreambas series de datos (Gráfica III) se pueden extraer varias conclusiones.

GRÁFICA III – Relación entre representación general y especializada en salud laboral en EU-28

Fuente: Sixth European Working Conditions Survey (Eurofound, 2015). Cálculos y elaboración propia.

37 En primer lugar, que existe una correlación positiva entre dichos sistemas derepresentación (R2= 0,540; p<0.000), por lo que aquellos países con mayor densidad deafiliación sindical también presentan una mayor tasa de representación especializadaen salud laboral, debido a que en la mayoría de los casos los/las delegados/as deprevención son elegidos/as por la representación sindical (Payá, 2014). En segundolugar, se observa como prácticamente la mitad de las empresas de EU-28 tienerepresentación tanto general como especializada, pero sin embargo, existe una elevada


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heterogeneidad: mientras que los países del sistema escandinavo presentan unacobertura representativa en torno al 80 % de los centros de trabajo y los del áreagermánica o centro europea próximos a la media, los países del área oriental y sur deEuropa registran, en términos generales, resultados muy por debajo de la media, lo quepodría explicar en parte, tal y como manifestaban los estudios previos, la elevada tasade accidentes de trabajo de los países del sur.

38 Diferentes características estructurales (históricas y culturales) y coyunturales(regulación legal, mercado laboral y ciclo económico) podrían explicar laheterogeneidad del poder asociativo entre los países europeos. En referencia a lasprimeras características, diferentes estudios comparados de los sistemas de relacioneslaborales (Crouch, 2017; Lehndorff et al., 2017) ponen de manifiesto que los países delsistema escandinavo presentan elevada cobertura representativa derivada, entre otrascausas, de su tradición socialdemócrata, una cultura de cooperación entre capital ytrabajo proyectada a través de la concertación social tripartita y la implementación delsistema Ghent, en el que los sindicatos participan institucionalmente en la gestión delas prestaciones por desempleo.

39 Por el contrario, el sistema de relaciones laborales del sur de Europa, se hacaracterizado históricamente por una mayor conflictividad entre capital y trabajo,mayor intervención estatal en la regulación de las normas de empleo y la extensión ergaomnes (eficacia general) de los convenios colectivos, lo que activa el efecto free rider,desincentivando la afiliación sindical y explicando, en cierta medida, el bajo poderasociativo (niveles de afiliación del 19,2 % de media en los países del sur, oscilando entreel 7,7 % de Francia y el 37,3 % de Italia). Sin embargo, dicho sistema garantiza, por otrolado, un elevado poder institucional, puesto que la eficacia general de los convenioscolectivos estatales y sectoriales negociados por los sindicatos más representativos seaplica a todas las personas trabajadoras, garantizando una cobertura de la negociacióncolectiva próxima al 80 %.

40 Por lo que refiere a las características coyunturales, la flexibilización y desregulaciónde las condiciones de trabajo no solo ha impactado directamente sobre la salud de laspersonas, sino que también lo ha hecho indirectamente, puesto que, las políticasneoliberales han debilitado los recursos de intervención de los sindicatos en la medidaque erosionan el poder estructural y este a su vez el poder asociativo. Así pues, es conocidoque altas tasas de desempleo, de rotación y temporalidad de los/as trabajadores/aslimitan su capacidad de negociación (poder estructural), siendo este uno de losprincipales motivos de desafiliación (poder asociativo), debilitando con ello la capacidadde presión sindical en los centros de trabajo en defensa, entre otras reivindicaciones, delas relacionadas con la salud laboral y la prevención de riesgos (Alós et al., 2013).

41 De hecho, al comparar los datos registrados de las dos Encuestas Europeas de Empresassobre Riesgos Nuevos y Emergentes (ESENER-1) realizadas en 2009 (EU-OSHA, 2009) yESENER-2 en 2014 (EU-OSHA, 2014) sobre la tasa de representación especializada ensalud laboral (Gráfica IV), se observa una reducción de la cobertura de delegados/as deprevención, que paso de una tasa media europea del 64,6 % en el 2009 al 58 % en 2014,registrándose un descenso generalizado del nivel de cobertura, siendo muysignificativo el caso de España que pasó de una tasa del 70 % en 2009 a un 51 % en 2014,lo que se explicaría por las altas tasa de desempleo y temporalidad del mercado detrabajo español y la consiguiente erosión de los recursos de intervención sindical.


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GRÁFICA IV – Evolución tasa de delegados/as de prevención en EU-28 (2009 y 2014)

Fuente: ESENER (EU-OSHA, 2009) y ESENER 2 (EU-OSHA, 2014). Elaboración propia.

42 El efecto combinado del reducido poder asociativo de la representación general yespecializada del sistema mediterraneo de relaciones laborales junto a la erosión ydesregulación de las condiciones de trabajo, ha hecho que Francia y Portugal comotambién Grecia, registren la tasa más baja de delegados/as de prevención situándose enun 25 %, 24 % y 17 % respectivamente, muy lejos de la media europea situada en un 58%.

43 El tamaño de la empresa es, también, un factor determinante, tanto a nivel derepresentatividad, siendo menor en las pymes que en las grandes empresas (Alós et al.,2013) como a nivel cualitativo, puesto que disponenmenos recursos materiales yhumanos para gestionar la salud laboral (Walters, 2004), y la existencia de una culturapaternalista y autoritaria impide la participación sindical (Narocki, 1997), lo quevendría a explicar la mayor tasa de accidentes de trabajo en las pymes (ver Tabla I).

44 En términos de cobertura de la representación especializada, al igual que larepresentación general, la mayoría de los países de Europa establecen, portransposición a sus legislaciones nacionales de la Directiva Marco 89/391-CEE, umbralesmínimos de trabajadores/as para poder realizar elecciones de órganos derepresentación especializados (Payá, 2014). Así, la Ley 102/2009, de 10 de Septiembresobre el Régimen Jurídico da Promoción de la Seguridad y Salud en el Trabajo (enadelante LPSST) de Portugal o la Ley 31/1995, de 8 de noviembre, de Prevención deRiesgos Laborales (en adelante LPRL) de España, fijan el número de representantesespecializados en función de la plantilla del centro de trabajo (Tabla VII). Ahora bien,mientras que en Portugal no existe umbral mínimo para elegir un o una represente, enEspaña es necesario que la empresa cuente, al menos, con seis trabajadores/as. TABLA VII – Número de representantes especializados por tamaño del centro de trabajo en Portugaly España

Portugal España


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N.º de trabajadores/as N.º de representantes N.º de trabajadores/as N.º de representantes

Menos de 61 1 De 6 a 49 1

De 61 a 150 2 De 50 a 100 2

De 151 a 300 3 De 101 a 500 3

De 301 a 500 4 De 501 a 1.000 4

De 501 a 1000 5 De 1001 a 2000 5

De 1000 a 1500 6 De 2001 a 3000 6

Más de 1500 7 De 3001 a 4000 7

- - De 4001 en adelante 8

Fuente: Artículo 21.4 de la LPSST, y artículos 34.1 y 35.2 de la LPRL. Elaboración propia.

45 A todo ello, cabría añadir, que la configuración española socava las posibilidades derepresentación en las empresas más pequeñas puesto que recaerá sobre la mismapersona las competencias de la representación general y la específica en salud laboral,acumulando ambas funciones ya que estos últimos son elegidos por y entre larepresentación general. Sin embargo, la ley no amplia el crédito de horas derepresentación más allá de las atribuidas al sistema general (art. 37.1 de la LPRL) salvoque se disponga por negociación colectiva (Disposición transitoria primera de la LPRL),mientras que la normativa portuguesa, otorga cinco horas al mes exclusivas para ladefensa de los intereses específicos en salud laboral (art. 21.7 de la LPSST).

46 Así las cosas, la configuración legal de los órganos de representación especializados ensalud laboral vendría a explicar la desigual cobertura entre las empresas más pequeñasy las de mayor tamaño tanto para los países del sur como para la media europea, salvoItalia, por las particularidades que a continuación analizamos (Gráfica V).


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GRÁFICA V – Tasa de representación especializada según el tamaño de empresa

Fuente: ESENER-2 (EU-OSHA, 2014). Elaboración propia.

2.2.2. El modelo italiano. Los/las delegados/as de prevención territoriales comorecurso de poder asociativo en salud laboral

47 El caso italiano merece un análisis pormenorizado por cuanto que, a diferencia delresto de países del sur, presenta una densidad de delegados de prevención del 88 % (verGráfica IV) situándose como el país europeo con mayor cobertura en la materia, pordelante incluso de los países del área escandinava, lo que podría explicar en ciertamedida su menor tasa de accidentes de trabajo (ver Gráfica I). Sin embargo, es uno delos pocos países en los que la representación general y especializada no correlacionapuesto que la tasa de afiliación sindical (presencia) se sitúa en torno al 37 %.

48 Esta situación se explica históricamente por el denominado “modelo obrero italiano”construido a partir de los años 60 y 70 del siglo XX y que ha tenido un importanteimpacto en el cambio del enfoque tradicional de la seguridad y salud laboral de todaEuropa. Dicho modelo se caracterizó por una fuerte lucha sindical y movilizacionesmasivas en defensa de la salud en el trabajo bajo dos principios. El primero “la salud nose vende” en la medida que los sindicatos no se planteaban como objetivo conseguirmejores condiciones económicas a través de la negociación colectiva mediante plusesde toxicidad o nocturnidad, sino que la lucha sindical se centraba en reivindicar laeliminación de los riesgos laborales. El segundo “la salud no se delega” que inspiró laactual Directiva Marco, puesto que se centra en la subjetividad de la salud laboral. Asípues, la lucha del movimiento sindical italiano reclamaba la participación obrera en latoma de decisiones en salud laboral y que no se vinculara únicamente a decisionestecnocráticas de especialistas en prevención de riesgos (Vogel, 2016b).

49 Dicha tradición histórica derivó en que los sindicatos italianos crearan, entre otras, lafigura de los/as delegados/as de prevención territoriales por sector y localizacióngeográfica, los/as llamados/as rappresentante dei lavoratori per la sicurezza territoriale o dicomparto (“representantes/as de los/as trabajadores/as territoriales o sectoriales parala seguridad”), configurando una red de representantes especializados/as de carácter


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supraempresarial que ha permitido la penetración sindical en las empresas máspequeñas sin representación propia (Fulton, 2018), lo que explica su elevada coberturarepresentativa que llega, incluso, al 81 % en las empresas más pequeñas (ver Gráfica V).

50 Así pues, observado el éxito del modelo italiano, la estrategia sindical del resto depaíses del sur podría pasar por consolidar sistemas de representación territorial paraaumentar la cobertura en un tejido empresarial fragmentado. En este sentido, elartículo 35.4 de la LPRL permite en España crear, a través de la negociación colectiva,ámbitos de representación distintos a los propios del centro de trabajo pero, sinembargo, pocos convenios recogen dichas cláusulas. La experiencia más desarrollada enEspaña son los Acuerdos Interconfedereales para la creación y regulación de losdelegados territoriales de prevención en el Principado de Asturias que llevanaplicándose desde el año 2005 con resultados positivos (González-Lada, 2006). 2.2.3. Erosión y límites del poder institucional en salud laboral

51 Las políticas neoliberales también han erosionado los recursos de poder institucionalen los que históricamente se ha sostenido la fortaleza sindical del sistema latino omediterráneo de relaciones laborales. Las reformas laborales de 2012 fueron utilizadaspara debilitar el poder institucional de los sindicatos portugueses y españoles. Tal comoseñalan Alós et al. (2017), en España, la erosión de la negociación colectiva se articuló entres frentes: a) descentralización de ámbitos priorizando el convenio de empresa alsectorial; b) facilitación a las empresas del descuelgue o inaplicación de los conveniossectoriales y c) eliminación de la ultraactividad, es decir, del carácter vinculante de losconvenios colectivos tras expirar su período de vigencia y en tanto se renovaba sucontenido.

52 Leite et al. (2014) y Lima (2016) describen una situación similar en Portugal, sinembargo, la diferencia más importante, radica en que la normativa portuguesa halimitado la extensión erga omnes de los convenios colectivos, lo que podría explicar (verTabla VIII) que a partir de 2012 empiece a reducirse notablemente la tasa de coberturade los convenios publicados anualmente (del 48,4 % en 2012 al 19,3 % en 2015). Noobstante, la cobertura total en 2015 fue del 80,1 %. A pesar de ello esta estadísticageneral puede ser engañosa, en la medida que los acuerdos anteriores a la reformalaboral todavía están vigentes. Mientras tanto, España al preservar la extensión de losconvenios y sus cualidades durkheimianas, mantendrían el poder institucional en unatasa de cobertura estable alrededor del 70 % (Rigby y García-Calavia, 2018). TABLA VIII – Evolución de la tasa de cobertura de la negociación colectiva en Portugal y España(2005-2015)

Portugal España

AñoConveniospublicados

Tasa decobertura deconveniospublicados

Tasa decobertura deconvenios envigor

Conveniospublicados

Tasa decobertura deconveniospublicados

Tasa decobertura deconvenios envigor

2005 255 40,9 84,8 2406 27,1 67,1

2006 244 52,6 83,6 2323 22,0 67,8


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2007 251 53,4 83,9 2269 30,2 68,4

2008 296 65,5 83,7 2376 24,8 71,0

2009 251 50,6 83,5 1752 19,5 72,8

2010 230 54,1 85,4 1460 16,9 69,2

2011 170 48,4 84,6 1445 17,7 69,3

2012 85 13,7 81,9 1580 21,9 69,3

2013 94 10,1 81,0 2501 37,3 73,0

2014 152 10,0 80,5 1859 15,2 72,1

2015 138 19,3 80,1 1606 24,0 69,2

Fuentes: Direção-Geral do Emprego e das Relações de Trabalho (DGERT)/Centro de RelaçõesLaborais (CLS) para Portugal; Ministerio de Trabajo, Migraciones y Seguridad Social (MITRAMISS)para España. DGERT/CLS. Negociação coletiva em números. Consultado el 08.11.2019, en https://www.crlaborais.pt/inf-estatistica; MITRAMISS. Estadística de Convenios Colectivos de Trabajo. Consultado el 08.11.2019, en http://www.mitramiss.gob.es/estadisticas/cct/welcome.htm.

53 Ahora bien, el hecho de mantener cierta tasa de cobertura puede encubrir lasdificultadas de negociar aspectos cualitativos. De hecho, los estudios realizadosmuestran cómo condiciones de trabajo esenciales para la salud laboral (horario detrabajo, ritmos de producción, distribución regular de horarios etc.) habríanexperimentado una fuerte erosión (Leite et al., 2014); Lima, 2016). A ello habría quesumar el retroceso en las estadísticas de las cláusulas cualitativas referidas a la salud yseguridad en el trabajo. En este sentido, tal y como se muestra en la Gráfica VI todos losaspectos relativos a la seguridad y salud laboral en España habrían sufrido unasignificativa reducción.


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https://www.crlaborais.pt/inf-estatistica




http://www.mitramiss.gob.es/estadisticas/cct/welcome.htm

http://www.mitramiss.gob.es/estadisticas/cct/welcome.htm

GRÁFICA VI – Evolución de las cláusulas cualitativas sobre salud laboral en España (2012-2018 –datos provisionales)

Fuente: Ministerio de Trabajo, Migraciones y Seguridad Social (MITRAMISS). Elaboración propia.

54 Finalmente, las políticas de austeridad también habrían debilitado la capacidad deintervención de la Inspección de Trabajo, encargada de vigilar y controlar elcumplimento normativo en materia de salud laboral. Dicha institución haexperimentado un fuerte descenso en el número de inspectores/as en los países del surde Europa, como acreditan los respectivos informes anuales de las Inspecciones deTrabajo6 (Portugal ha pasado de disponer 359 inspectores/as en 2012 a 314 en 2016,España de 1871 a 1797 y Francia de 1428 a 745 para el mismo periodo). A todo ellohabría que sumar que a diferencia del resto de países europeos que disponen unainspección especialista en salud laboral, en los del sur la inspección es de caráctergeneralista, acumulando una elevada carga de trabajo por tener que controlar elcumplimiento de toda la normativa, tanto la relativa a las relaciones de empleo yseguridad social como la correspondiente a la salud laboral (Castejón y Crespán, 2007).En definitiva, se trata de políticas deliberadas para socavar el poder de la Inspección deTrabajo y a su vez, de reducir las posibilidades de presión sindical para fortalecer laspolíticas de flexibilización empresarial.

Conclusiones

55 La investigación, cuyas principales conclusiones hemos presentado, tenía por objetoanalizar el impacto de las políticas de austeridad económica y desregulación impuestaspor la Troika sobre la salud laboral de los países del sur de Europa.

56 Por un lado, se han identificado importantes desigualdades sociales entre el capital ytrabajo, en la medida que los/las trabajadores/as por cuenta ajena en Portugalpresentan cinco veces más probabilidades de sufrir accidentes de trabajo que los/lasempresarios/as, como resultado de las condiciones de trabajo precarias a las que se


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encuentra sometida la población asalariada. Dicha precariedad afecta, asimismo, deforma desigual, siendo los/las trabajadores/as de sectores precarios de la construccióne industria y los/las de las pequeñas empresas los/las que presentan mayores índices deaccidentabilidad laboral tanto en España como en Portugal. En segundo lugar, laspersonas más jóvenes son las que refieren mayor número de accidentes, debido a suselevadas tasas de precariedad contractual ya que, como se ha analizado, la contratacióntemporal y la reducida antigüedad devienen como factores determinantes de lasiniestralidad laboral.

57 Por otro lado, tanto el estudio de los movimientos sindicales sobre la lucha contra lacéruse y el fósforo blanco como el análisis de investigaciones empíricas, han acreditadoel impacto positivo de la representación sindical especializada (delegados/as deprevención y comités de salud laboral) sobre la mejora de los estándares de saludlaboral y la reducción de la siniestralidad. Sin embargo, las políticas neoliberales,también habrían debilitado los recursos de poder sindical (poder asociativo– reducciónde la tasa de representación; poder institucional– erosión de la cobertura de lanegociación colectiva en salud laboral), por lo que el efecto combinado de ladegradación del mercado de trabajo junto al deterioro de las instituciones derepresentación sindical explicaría las elevadas tasas de accidentabilidad en los paísesdel sur de Europa – a excepción del caso italiano, cuyo modelo de delegadosterritoriales de prevención operaría como alternativa estratégica.

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http://www.relats.org/documentos/SST.Europa.Vogel2016.pdf

NOTAS1. La precariedad laboral tienes múltiples dimensiones, entre otros, el trabajo no declarado einformal, sin embargo, para realizar análisis estadísticos comparados, solo se disponen datoscuantitativos sobre algunas de las principales dimensiones de la precariedad (contratacióntemporal, antigüedad, segmentación).2. Gabinete de Estratégia e Planeamento (GEP/MTSSS). Consultado el 22.12.2018, en http://gep.msess.gov.pt/estatistica/acidentes/index.html.3. Anuario de Estadísticas del Ministerio de Empleo y Seguridad Social. Consultado el 22.12.2018, enhttp://www.mitramiss.gob.es/estadisticas/eat/welcome.htm.4. EPA Portugal. Consultado el 21.12.2018, en https://ine.pt/xportal/xmain?xpid=INE&xpgid=ine_indicadores&indOcorrCod=0005543&contexto=bd&selTab=tab2; EPA España.Consultado el 18.12.2018, en https://www.ine.es/prensa/epa_prensa.htm. 5. Según Monjardino et al. (2017: 7) en Portugal “El 97% de las empresas son de 10 o menostrabajadores, las cuales concentran al 29% de los trabajadores, si bien 773 (0,1% del total) deempresas de más de 250 trabajadores concentran un 26% de los trabajadores”.6. Portugal: http://www.act.gov.pt/(pt-PT)/SobreACT/DocumentosOrientadores/RelatorioActividades/Documents/RelatorioAI2016_20170910.pdf. España: http://www.mitramiss.gob.es/itss/ITSS/ITSS_Descargas/Que_hacemos/Memorias/Memoria_2016.pdf.Francia: https://travail-emploi.gouv.fr/IMG/pdf/l_inspection_du_travail_en_france_en_2016.pdf. Documentos consultados el 20.12.2018.

RESÚMENESEl modelo neoliberal de gestión de la crisis económica (austeridad, precariedad laboral y recortesen el Estado de Bienestar) ha provocado un aumento de las desigualdades sociales, ladesregulación del mercado de trabajo y el debilitamiento de sus principales instituciones(derecho del trabajo, sindicatos y negociación colectiva), operando, asimismo, como factoresdeterminantes del repunte en los índices de accidentes laborales, especialmente en el sur deEuropa.

The neoliberal model in the economic crisis management (austerity, job insecurity and cuts inthe welfare state) has caused an increase in social inequalities, the deregulation of the labormarket and the weakening of its main institutions (labor law, trade unions and collectivebargaining), which have beendecisive in the upturn in labor accident rates, especially in southernEurope.

ÍNDICE

Palabras claves: crisis, desigualdades, precariedad, salud laboral, sindicalismoKeywords: crisis, inequalities, occupational health, precariousness, trade unionism


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http://www.mitramiss.gob.es/estadisticas/eat/welcome.htm

http://www.mitramiss.gob.es/estadisticas/eat/welcome.htm

https://ine.pt/xportal/xmain?xpid=INE&xpgid=ine_indicadores&indOcorrCod=0005543&contexto=bd&selTab=tab2




https://www.ine.es/prensa/epa_prensa.htm

https://www.ine.es/prensa/epa_prensa.htm

http://www.act.gov.pt/(pt-PT)/SobreACT/DocumentosOrientadores/RelatorioActividades/Documents/RelatorioAI2016_20170910.pdf




http://www.mitramiss.gob.es/itss/ITSS/ITSS_Descargas/Que_hacemos/Memorias/Memoria_2016.pdf




https://travail-emploi.gouv.fr/IMG/pdf/l_inspection_du_travail_en_france_en_2016.pdf




AUTOR

RAÚL PAYÁ CASTIBLANQUE

Instituto Universitario de Estudios de la Mujer, Universitat de ValènciaAvda. Blasco Ibáñez, 13, 46010 València, Españ[email protected]


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The Italian National Health Serviceafter the Economic Crisis: FromDecentralization to DifferentiatedFederalismO Serviço Nacional de Saúde italiano após a crise económica: da descentralizaçãoao federalismo diferenciado

Stefano Neri

EDITOR'S NOTE


1. The Economic Crisis and the National HealthService in Italy

1 Italy was one of the European Union (EU) countries hardest hit by the recession thatbegan in 2008. The prolonged economic crisis presented a fluctuating trend,characterized by two peaks (Table 1): the first was in 2008 and especially in 2009, whenthe Italian Gross Domestic Product (GDP) declined by 1.1% and 5.5% respectively fromthe previous year. There was an overall weak recovery in the following two years, whilein 2012 the crisis heightened and the GDP dropped by 2.8%, followed by a furtherdecline of 1.7% in 2013. In 2014-2015 the GDP growth trend was very slack and became alittle more sustained in recent years (1.1% in 2016 and 1.6% in 2017), although, in realterms, in 2017 the GDP had not recovered the pre-crisis level yet, being more than 5%below that of 2007 (Eurostat database). Provisional data for 2018 and forecasts for 2019seems to indicate a substantial weakening in the recovery. In all these years, the GDP


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growth rates were considerably lower than those of the 28 EU countries (Table 1).Similar differences emerge also comparing Italy only with the countries of the Euroarea.

TABLE 1 – GDP Rates (Percentage of Change from Previous Year)

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Italy 1.5 -1.1 -5.5 1.7 0.6 -2.8 -1.7 0.1 0.9 1.1 1.6

EU 28 3.1 0,5 -4.3 2.1 1.8 -0.4 0.3 1.8 2.3 2 2.4

Source: Eurostat – National Accounts and GDP Dataset (accessed on 27.12.2018, at https://ec.europa.eu/eurostat/data/database).

2 The recession had a very strong impact on the relationship between the GDP and publicdebt. Since 1991-1992, this ratio had always been at more than 100%, one of the highestin Europe – except for 2007 (99.8%). However, since the start of the economic crisis ithas progressively increased reaching close to 130% of the GDP in 2013 and surpassingeven this peak in the following years, with a tendency to level off (Table 2).

TABLE 2 – General Government Gross Debt in Italy (Percentage of GDP)

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

99.8 102.4 112.5 115.4 116.5 123.4 129 131.8 131.6 131.4 131.2

Source: Eurostat – General Government Gross Debt Dataset (accessed on 28.12.2018, at https://ec.europa.eu/eurostat/data/database).

3 Beyond the data, the financial crisis became particularly serious in 2011-2012, since itwas accompanied by the widespread perception – by the international markets andEuropean institutions – that the Italian government was no longer able to cope with thesituation and bring the debt under control (Jones, 2012). As is known, this resulted in asovereign debt crisis, expressed by the increased interest rates on Treasury bonds andthe spread relating to German government bonds. Politically, the crisis resulted in thefall of the Berlusconi Government, at the end of 2011, which was replaced by a“technical” executive, headed by the economist Mario Monti.

4 In the context of a protracted financial crisis and lack of confidence of the internationalenvironment, as well as prolonged stagnation and recession, strict measures had to betaken to control the budget deficit, reduce expenses and increase public revenues. Insome areas, these measures were accompanied by structural reforms, as in the case ofpensions and, later, of labour market, while this was not the case in health care.

5 Austerity policies, the details of which will be further discussed, had crucial goals forgovernment expenses, including staffing costs. The restrictive measures taken since2008 have focused on the public sector with varied intensity (Bordogna and Neri, 2014),fully involving health care. In this sector, the overall effect of these measures has beento recalibrate expenditure levels already lower than the average values recorded incomparable continental and Northern European countries, and in line with the other


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countries of Southern Europe (in particular Spain and Portugal). In Italy, in 2015-2016,the total health expenditure in fact amounted to 8.9-9% of the GDP (+ 0.7-0.8%compared to 2007), two points (or more) below than in France, Germany and Sweden,which traditionally have expenditures higher than Italy, and also nearly a point lessthan in the United Kingdom (UK), which has always been a very parsimonious country.Provisional data for 2017 and estimations for 2018 confirm this trend (OECD HealthStatistics).1

6 If we look only at public expenditure, the picture does not change. In terms of GDP,public expenditure is lower than in the main continental and Northern Europeancountries (Table 3). Starting from a pre-crisis value of 6.3% (2007), the Italiangovernment expenditure-GDP ratio did not grow even by half a percent in the followingdecade (6.6% in 2016 and in 2017 estimation), despite the inevitable increase in demandfor services – with a steadily aging population – and despite the increase in the costs ofimplementing new technologies in diagnostic and therapeutic services. Similarly,public expenditure per capita on health services increased of less than 19% from 2007to 2016, a share much lower than in the main continental and Northern Europecountries reported in Table 3.

7 Italian trends in public expenditure on health are more similar to those of otherMediterranean European countries such as Portugal and Spain, although, from 2007 to2016, the growth of expenditure per capita in Spain was considerably higher (24.5%).Again, estimations for 2017 confirm the picture emerging from Table 3. Table 3 – Levels of Current Public Expenditure on Health Care

Share of GDP (%) Per Capita (US$PPP) Growth of expenditure per capita (%)

2000 2007 2016 2000 2007 2016 2007-2016

France 7.5 7.8 8.7 1,977 2,715 3,957 45,7

Germany 7.8 7.6 9.5 2,120 2,773 4,612 66,3

Sweden 6.3 6.6 9.2 1,856 2,681 4,466 66,6

UK 4.8 6.1 7.7 1,242 2,144 3,312 54,5

Italy 5.5 6.3 6.6 1,488 2,150 2,554 18,8

Portugal 5.9 6.3 6.6 1,114 1,601 1,846 15,3

Spain 4.9 5.7 6.4 1,047 1,857 2,320 24,9

Source: OECD Health Statistics (accessed on 30.12.2018, at http://www.oecd.org/els/health-systems/health-data.htm).

8 At the same time the share of private health expenditure over total expenditure onhealth, while diminishing in France, Germany and Sweden, increased in the UK, Italyand in other Southern European countries (Table 4). In Italy, from 2007 to 2016 itshifted from 22.5% to 25.5% of total health expenditure, therefore coming to representmore than a quarter of total health expenditure (with OECD provisional data and


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estimations showing a further increase for 2017). This brought the level of privatehealth expenditure closer to that of Spain.

TABLE 4 – Private Health Expenditure in Share of Total Health Expenditure (%)

2007 2016 Difference 2016-2007

France 22.8 17.1 -5.7

Germany 24.9 15.4 -9.5

Sweden 18.1 16.5 -1.6

UK 18.3 20.5 2.2

Italy 22.5 25.5 2.5

Portugal 31.3 33.6 2.3

Spain 27.3 28.8 1.5

Source: OECD Health Statistics (accessed on 30.12.2018, at http://www.oecd.org/els/health-systems/health-data.htm).

9 In the Italian case the out-of-pocket component is very high, being more than 90% ofthe total private health expenditure. However, the growth of private healthexpenditure during the crisis was due to the insurance component, even more than theout-of-pocket factor. In this regard, one of the most recent transformations that hastaken place in Italy in relation to private health expenditure is the spread ofsupplementary, or integrative, occupational health funds for workers and theirfamilies, introduced or reintroduced from national negotiations or unilateral initiativesmade by companies. Almost non-existent at the end of the 1990s, supplementaryoccupational health funds have rapidly increased in the last decade, to cover 35% of thetotal number of employed persons. This threshold is particularly high when comparedwith the more marginal role that such insurance programs play in health care in otherEuropean countries (Natali and Pavolini, 2014). The increasing popularity ofoccupational health funds is due primarily to the dynamics inherent in the industrialrelations system during the crisis. However, it also reveals the state of health andcoverage of the Italian National Health Health Service (NHS). By increasingly fundingthe provision of basic health services, such as diagnostics and specialized care thatshould be covered by the NHS, it is clear how these funds are often operating insubstitution of the NHS, rather than as a complement to the latter, as required by law(Neri, 2012). As these funds are concentrated on employees in the medium and bigfirms, mainly located in the north of Italy, the spread of occupational funds bringsserious risk to deepen the traditional differences existing in service access and qualitybetween the north and the south of the country (Arlotti et al., 2018).


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2. Austerity Policies in the NHS

10 Within a general approach aimed at reducing public expenditure and the weight of thepublic sector in the economy, the austerity policies directed to the NHS had as mainobjective the containment and control of public health expenditure, if not itsreduction. This was done in a context where health expenditure (public or private) isexpected to grow in the medium and long term, for the reasons we have already brieflymentioned.

11 In the Italian highly regionalized NHS, control of health expenditure by the centralgovernment was pursued primarily through extremely limited increases and, in somecases, reductions in the level of funding attributed by the central government to theRegions to finance the “Essential Levels of Health Care” (Livelli Essenziali di Assistenza, orLEAs), that is the set of services to be provided nationwide. Absolute values andpercentages of annual funding increases confirmed a stagnation in the centralgovernment appropriations from 2010 onwards, with generally very reduced surges butalso drops compared to the previous years, in 2013 and in 2015 (Table 5). TABLE 5 – Financing of the Central Funding for LEAs

Financing (in millions of €) Percentage of change from previous year

2007 97,6 -

2008 101,6 4.1

2009 104,2 2.6

2010 105,6 1.3

2011 106,9 1.2

2012 108,0 1.0

2013 107,0 -0.9

2014 109,9 2.7

2015 109,7 -0.2

2016 111,0 1.2

2017 112,6 1.4

2018 113,4 0.7

Source: Ministero della Salute (accessed on 31.12.2018, at http://www.salute.gov.it/portale/home.html).

12 One could object that in the first part of the 2000s the yearly growths were moresubstantial. However, we should remember that the restrictions in the central funds


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allocated in the last seven-eight years would, comparatively speaking, have had animpact on very low expenditure levels (Giarelli, 2017).

13 The level of annual funding of LEAs is calculated in the budget laws, called “stabilitylaws”. The level is negotiatied between the State and the Regions within the State-Regions Conference (see below) and ratified in official acts and documents such as theState-Region Agreements or the Pacts for Health. However, the Parliament and thecentral government can modify the concerted funding levels, as has always occurred infact, after the beginning of the crisis with reductions in the originally agreed funds.

14 Besides the containment of general central funding, austerity policies addressed thecontrol of specific sources of expenditure arising from the acquisition of productioninputs. The main cost containment programmes started in 2009-2010 and intensified inthe following years, culminating in the so-called “Spending Review” on publicadministration, promoted by the Monti government in 2012 (Law Decree No. 95/2012).2

The austerity measures then continued roughly until today, albeit with less intensity in2017-2018. Targets like the following were pursued:3

“rationalization” policies on pharmaceutical expenditure, which included spending caps onthe global expenditure, passed from 16.4% of the total NHS financing in 2008 to 14.85% in2017, incentives for generic drugs, reductions in quotas attributable to pharmaceuticalcompanies, wholesalers and pharmacists on the sale price of drugs, as well as a generalreview of the remuneration system of the drug distribution chain;

reduction in hospitalization rates, setting, in 2012, the target of 160 total admissions for1,000 inhabitants (of which 25% for the outpatients), against a rate which in 2010 wascalculated at 175-180 admissions for 1,000 inhabitants. In the same year national legislationintroduced also a mandatory statute, by Regions, to reduce the number of hospital bedsfrom 4 to 3.7 per 1,000 inhabitants, including 0.7 beds for rehabilitation and long-termnursing care. The reduction was borne by the public providers for a quota of not less than50%;

redefinition, in a generally restrictive sense, of the criteria used to set the regional tariffs(linked to DRG-like systems), for inpatient and outpatient services provided to the NHS;

general restrictions of the expenditure on purchases of goods and services. In 2012-2013there was a 10% reduction of all existing contracts for the procurement and supply of goodsand services stipulated by the NHS health authorities. These drastic measures wereprogressively accompanied by instruments that monitored and controlled the conclusionand implementation of purchase contracts;

increasing revenues: by increasing the co-payments for citizens, with the introduction orrescheduling of copayments on first aid, specialized outpatient and pharmaceuticalindustries. In this field, the most discussed measure was the “superticket”, a sharing of theexpense of 10 euros for each prescription for outpatient diagnostic and specialized services,introduced at the end of 2011. The Regions have made different choices regarding thesuperticket, accepting it indiscriminately, and modifying it according to income or, in somecases, denying it. This last option is spreading in 2018-2019.

15 These measures were added to those aimed at controlling staff expenditure in all publicservices (Bordogna and Neri, 2014), which are of particular significance due to theimportance of human resources in the health sector. There were two main types ofmeasures addressed to NHS staff: measures aimed at gradually reducing the number ofemployees and others at containing wages and salaries.

16 In the first case, at the end of 2006, and thus before the start of the crisis, a cap forpersonnel expenditure for 2007, 2008 and 2009, equal to the “corresponding amount of

1.

2.

3.

4.

5.


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the year 2004 reduced by 1.4%” (including costs for temporary employees andautonomous workers) was introduced in the NHS. This measure was first confirmed forthe three-year period 2010-2012, establishing that the cap was to be considered as netof expenses arising from contract renewals occurring after 2004. Then the sameconstraint was extended to 2013-2014 and in the following years, having been in forceuntil 2019. To meet the cap, Regions could adopt several measures of health facilitiesand service re-organization. However, a predictable result of the cap and other similarmeasures was a slow down and substantial stop in the staff hiring and turnover withinthe NHS health care organizations.

17 Between 2007 and 2015 the staff of the Italian NHS passed from 682,197 to 648,663 units,a drop of 33,534 units (-4.9%). The decline would be more pronounced (-6.5%) if we tookas reference the initial year of 2009, when the staffing of the NHS amounted to 693,716units (Ministero dell’Economia e delle Finanze, 2018). The decrease in the number ofstaff during the crisis was stronger in other areas of public administration, such as thecentral and local government, but it was nevertheless a significant drop, consideringthat the Italian health care service is understaffed compared to many Europeancountries (Vicarelli, 2015).

18 Staff hiring was re-opened in 2017-2018, especially after that the new national NHScollective agreeement signed in 2018 opened the possibility to hold extraordinarypublic competitions for the new recruitment of doctors, nurses and technical healthpersonnel. These measures were confirmed by the stability law for 2019, whichsuspended new hiring in a great part of public administration until November 2019.However, the pace of recruitment seems inadequeate to face the lack of health carestaff within the NHS, which will become more serious in the next years considering thepredictable wave of retirements connected to an aging labour force, especially amongdoctors (Vicarelli and Pavolini, 2015).

19 Furthermore, a second type of measures was introduced in 2008 and reinforced in2010-2011, which concerned the containment of wages for civil servants (Law DecreesNo. 78/20104 and No. 98/20115). These measures also affected employees in the NHS, aswell as independent professionals working for the NHS, starting from the generalpractitioners and paediatricians.

20 After very moderate wage increases in 2008-2009, equal to half of the increaseestablished in renewals for the periods 2004-2005 and 2006-07 (ARAN, 2011), national-level collective bargaining was suspended for two years, in 2010, for all 2.8 millioncontractualized public employees, including NHS staff. The suspension was thenextended until 2015, when a sentence of the Constitutional Court forced thegovernment to re-start the collective bargaining process in the public sector. A newnational NHS collective agreement for the period 2016-2018 was signed in May 2018,with modeste pay increases. Collective negotiations at decentralised level in the publicsector, including the NHS, were not frozen, but were put under very strict financialconstraints. The overall effect of these provisions was to freeze the salaries of NHSemployees for eight years, substantially to the levels of 2010.

21 In addition to these measures, there were also specific measures addressing the Regionsin conditions of high deficit in the health sector and therefore subjected to a recoveryplan, which will be dealt within the second part of the article.


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3. The Consequences of the Financial Crisis on Inter-Governmental Relations

22 The economic crisis and the austerity policies have favoured a partial reversal of thetrend in the evolution of relations between different levels of government compared toprevious decades. The increasing regionalization of the system, started at least sincethe 1990s, has given way to a complex set of dynamics characterized, on the one hand,by a re-assertion of the role of the central government in national health policies witha significant impact on spending, on the other hand, by a substantial (more thanformal) differentiation in the powers and responsibilities among the Regions,depending on whether or not they are subject to a plan for the reduction of healthdeficits. To understand these dynamics, it would be useful to reconstruct the reasonsand the characteristics assumed by the regionalization of the NHS starting from the1992-1993 reforms (for an historical and updated reconstruction).

3.1. Decentralization in the NHS: The Rise of Regionalism(1992-2008)

23 Unlike the oldest national health services, such as those of England or Sweden, theItalian NHS has always had a decentralized structure, in line with the ItalianConstitution. In a first phase (1978-1992) the powers and responsibilities were dividedamong the State, Regions and local government. With the reforms of 1992-1993(Legislative Decrees No. 502/1992 and No. 517/1993), instead, the regionalization of theNHS was introduced, together with its managerialization (France and Taroni, 2005;Giarelli, 2017). Although they drew origin from the debate launched in the mid-1980son the crisis of the NHS, the reforms were approved in the midst of the political andjudicial earthquake after the general elections of 1992 and the impressive wave ofcorruption scandals known as Tangentopoli (“Bribesville”), which brought to thecollapse of the old political system of the First Republic (1946-1992). To this, we mustadd also the context of the economic and financial crisis, which led to the devaluationof the national currency (the Lira) in September of that year. It was therefore necessaryto intervene on an expenditure area as important as health care with not only urgentausterity measures (cuts, expenditure caps, copayments and new taxes), but also withstructural measures. Apart from the contingent emergency, the reforms wereconsidered necessary to allow the entry of Italy into the euro currency, in compliancewith the convergence criteria laid down in the Maastricht Treaty signed in February1992.

24 In this context, regionalization is the result of a convergence of objectives between thepolicy makers operating at national and regional level (Maino, 2001). On the one hand,the central government and the Parliament were more than willing to transfer powersand responsibilities when, presumably, it would have been necessary to undertake apolicy of austerity and retrenchment in health care for several years. Regionaldecentralization was thus seen as a way to share or remove highly unpopular decisions.

25 On the other hand, regionalization was considered an opportunity for Regionaladministrators to make visible and legitimize their level of government which, unlikethe municipalities, had only been established for some decades and was perceived bythe citizens as distant and not very visible. In particular, the implementation of


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1992/1993 reforms allowed Regional Governments to initiate policies that could instateprinciples and core values (trust in the public or in private sector, the State or themarket) that were distinct and clearly recognizable by the general public. In particular,the adoption of managed competition (Enthoven, 1985), which evolved into managedcooperation (Light, 1997), gave Regions the opportunity to implement quite divergentpolicies, in terms of organisation and regulation of the single Regional Health Services.

26 Regionalization responded not only to political, but also economic rationality criteria.The Regional level of government seemed in fact to be in the best position to planservice organisation and distribution on the territory, being able to respond adequatelyto local demands and needs and, at the same time, to keep under control the local“particularisms” that had emerged in an uncontrolled manner in previous decades. Infact, the regionalization of the NHS undertaken from 1992-1993 was at the same time aprocess of decentralization from the State to the Regions and of centralization by thelocal government to the regional level. Moreover, there was the conviction that greaterautonomy and empowerment of the Regions could push those of the South to promotepolicies to reduce existing disparities in service access and quality, more effectivelythan what the central State had been able to do up to that point.

27 The main powers in planning, organization and management of health services werethen attributed to the 20 Regions and the Autonomous Provinces of Trento andBolzano. New NHS providers, the local health authorities (Aziende Sanitarie Locali) andthe autonomous hospitals (Aziende Ospedaliere) were instituted as Regional entities andwere organized according to the New Public Management principles.

28 Regionalisation was then strengthened by the Constitutional reform introduced in 2001and confirmed by the failures of subsequent attempts of Constitutional reforms in 2006and 2016. According to current regulation, the State is in charge of defining the above-mentioned Essential Levels of Health Care, or LEAs, and should guarantee Regions theeconomic resources necessary for LEA provision. NHS central funding for LEAs isdefined through negotiations between the central government and Regions.

29 The Regions have great freedom in organization and management of their RegionalHealth Services. Starting from the second half of the 1990s, different Regional healthcare models emerged, characterized by regulatory structures marked by hierarchicalintegration, cooperation or competition between purchasers and service providers(Mapelli, 2007; Neri, 2011). These institutional and organizational differences amongRegional Health Services still exist, although some convergence processes emerged inthe 2000s (Maino and Neri, 2011).

30 NHS regionalization included a certain degree of fiscal autonomy, even if veryrestricted (see Bordignon et al., 2002), as well as the possibility of introducing co-payments for drugs and outpatient services at Regional level. In 2009, fiscaldecentralization could have expanded considerably after the approval of Law No. 42;6

however, the implementation of this law was hampered by many difficulties, and theeconomic and financial crisis caused its postponement. 3.2. The Re-Assertion of the Role of the State

31 The division of powers that emerged from the decade 1992-2001 required a permanentmechanism of negotiation and, possibly, cooperation between the State and theRegions to define national health policy. In fact, after 2001, the State (the central


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government and the Parliament) could not approve structural reforms such as those ofthe 1990s without the consent and involvement of the Regions, which was essential forreform implementation. However, the central government retained a considerablecontrol over financial resources, in particular those intended for the financing of theLEAs. Moreover, as the last ten years has clearly shown, the central government andthe Parliament retained a significant capacity of affecting NHS management andorganization at Regional and local level, by introducing national regulation whichRegions are then called to implement.

32 Since the late 1990s, the national health policy, like that of other policy sectors withhigh decentralization, has developed mainly through negotiated or joint forms ofpolicy-making, which is based on a system of Conferences between the State, Regionsand local government. Among those Conferences, the most relevant to health is theState-Regions Conference, established in 1988 and then reinforced in 1997 and 2003. Inthe State-Regions Conference, central government and Regions are represented at thehighest political level. Central (that is, national) government is represented by thePrime Minister and the National Ministers, while each Region is represented by itsRegional Governor and the Regional Ministers. In the case of health care, the Nationaland Regional Ministers involved in the policymaking will be the National Minister ofHealth and the Regional Minister of Health (one Minister of Health for each of the 20Regions). The majority of the most important health policy decisions are thus takenthrough “Agreements” or “Pacts” deliberated by the State-Regions Conference andtranslated into law by the Parliament (Carpani, 2006; Fargion, 2006).

33 The role of the State-Regions Conference was central to the process of making theRegions responsible for managing expenditure, which had become a crucial element inensuring the convergence of Italy to the Maastricht parameters, then translated intothe European Stability and Growth Pact. In a decentralized institutional frameworksuch as that of the 2000s, the involvement of the Regions was essential and ensured bymeans of acts, such as many State-Regions agreements and pacts (usually called “Pactsfor Health”), which have been signed within the State-Regions Conference between thecentral government, on one side, and the Regions, on the other, over the last 20 years.

34 Although none of regulatory changes had modified the balance of the powers we havedescribed, the economic and financial crisis weakened the role of the Regions innational policy making, in favour of greater importance of the role played by thecentral government, the Ministry of Economy and Finance (MEF) and, indirectly, by theEuropean institutions. This was not a trend limited to health care, but in this area itwas perhaps more significant as regional decentralization was extended andconsolidated in other areas. Faced with this change, the State-Regions Conference lost,in substance though not in form, some of its importance in defining the national healthpolicy, in favour of a more one-sided process that took place within the centralgovernment, in cooperation with the EU and the European Central Bank.

35 This shift that started before the crisis grew from 2008-2009 and became particularlyevident after the explosion of the sovereign debt crisis of 2011-2012. The need to takeurgent measures – able to signal to international markets and the EU the willingnessand ability of the national government to bring the public debt under control – haveprompted approval of austerity packages by the central goverbment, which in greatpart had not been agreed upon and basically not even discussed with the Regions,Parliament and organized interests. The minimization of room for discussion and


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negotiation was motivated by the lack of time and alternatives in the face of thecommitments made with the EU and the need to reassure the markets. In this sense,justifying the making of unpopular decisions with the overriding need to abide byoverwhelming external restrictions was a very effective strategy to avoid negotiation,using a combination of blame avoidance and credit claiming (Bonoli and Natali, 2012).

36 These dynamics did not occur only in Italy but were common to all the Europeancountries most affected by the financial crisis and sovereign debt, namely those ofSouthern Europe (Portugal, Spain and Greece) and, in a partially different form, Ireland(Pavolini and Guillén, 2013; Pavolini et al., 2015; Asensio and Popic, 2019; Léon et al., 2015; Sotiropoulos, 2015). All the last mentioned countries were forced to adoptstructural reforms and strict austerity measures decided by the central government,with more or less direct interventions of the EU and, unlike what has happened in Italy,in various other situations of international financial institutions such as theInternational Monetary Fund (Greece, Portugal, Ireland). In this context, nationalgovernments and, within it, Prime Ministers and the Ministers of Economy and Financehave become guarantors and accountable at European and international institutionsfor the adoption of interventions or negotiations, according to each case, imposed bysuch institutions in exchange for direct or indirect financial support. Applying thesemeasures quickly and with little margin for change than those already defined atEuropean or international level, had somehow determined an exclusion of traditionalnegotiations with the parliaments, local government and organized interests.

37 In the Italian case, these trends seemed particularly evident in some reforms like thoseof pensions in late 2011 and the adoption of austerity packages on public expenditureand staff (Bordogna and Neri, 2014). In the health care sector, the heart of the decision-making process was shifted from the complex mediations between the centralgovernment, Parliament, Regions and also organized interests (i.e. doctors) to the top-down relations between European institutions and the central government, withinwhich the role of the Prime Ministers and the Ministers of Economy and Finance standout (Marangoni and Tronconi, 2014; Frisina-Doëtter and Neri, 2018a; 2018b).

38 The role of the Regions has significantly weakened in the definition of health policyand, consequently, also that of the State-Regions Conference, even if there were nochanges in the legislative assignments. This was particularly evident in the process ofdetermining the annual NHS central funding for LEAs. The definition of the allocationstook place through a negotiation between the State and the Regions, which resulted inagreements, such as the Pacts for Health 2007-2009, 2010-2012, 2014-2016. However,since 2010, the agreed funding has almost always been revised downwards by thestability laws or other austerity packages, with decisions substantially taken by thecentral government and, in particular, by the MEF, and has involved very limitedpossibilities or even the absence of modification by the Regions.

39 According to information gathered in some interviews carried by the author of thisarticle with some managers and officers of the State-Regions Conference in 2016, themost striking example of this process took place in the case of definition of the NHScentral funding for 2013. In this circumstance, the Regions protested loudly, but to noavail, against the downward revision of the NHS funding for 2013, which wassignificantly lower than that of 2012, both in percentage terms and in real terms (seeTable 5).


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40 The weakening of the role of the Regions in national policy making is not only due topolitical and institutional dynamics set in motion by the financial crisis, but also, inpart, by a series of scandals related to corruption or misuse of public resources,featuring Regional governments both in north and in the south of Italy. In the eyes ofthe public, Regional politicians thus began to appear among the major representativesof a “caste”, i.e. the political class, unable to administer public affairs efficiently anddedicated almost exclusively to its own particular interests. For a “young” institutionlike the Regional one, introduced only in 1970, this phenomenon translated into arather serious loss of legitimacy, to the point that, even in the national press, somecommentators began to wonder what the Regions were for. Doubts aboutregionalization or, at least, the way it was began to spread also among experts, in thelight of research that highlighted the persistence if not an increase in regionalinequalities, after 20 years of regionalism (Pavolini and Vicarelli, 2012; Toth, 2014).

4. From Territorial to Institutional Differences? Northand South between Greater Autonomy and CentralProtection

41 In a comparative perspective, OECD data show that, according to many indicators, theItalian NHS performs quite well in terms of health equity, service access and quality, aswell as of overall efficiency. Always in comparative terms, these performances by andlarge have not changed (or not yet), after the economic crisis (Mapelli, 2012; Giarelli,2017; Terraneo, 2018), although there are some signs of increase in health inequitiesamong social groups (Sarti et al., 2017) and some current trends – NHS underfunding,increase in the share of private health expenditure, spread of occupational funds –have a great potential to undermine the universalistic nature of the Italian NHS (Neri etal., 2017).

42 However, as it is well known, data at national level hide the existence of relevantinequalities between North and South in the service access and quality, as well as in theefficiency of the Regional health care systems. Although these differences arehistorically rooted, since 1990s they have increased rather than decreased (Pavoliniand Vicarelli, 2012; Toth, 2014, 2016; Sarti, 2017). Although over time the NHS exerted asignificant effort to reduce territorial differences in expenditure for health services(Mapelli, 2012), this was not translated into a correspondent reduction of thedifferences existing in terms of service quality and efficiency between different areas ofthe country. Quite the opposite, the North-South gap was widened in the years of NHSregionalization, instead of filled (Toth, 2014).

43 In this context, the economic crisis triggered relevant changes in the NHS governanceand in the relationships between State and Regions. First, as described in the previousparagraph, the crisis had contributed to determine a partial but significant re-centralization of national health policy making. Moreover, it promoted the re-assertionof the role of the State in the governance of the Italian NHS, by highlighting theimportance of some institutional mechanisms, which had been created before thecrisis. Even in this case, the central government was called to re-affirm its role to tackleproblems of financial nature.


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44 In fact, already in the mid-2000s, the inability of some Regions to keep their healthservice in a financial equilibrium had clearly emerged. Disputes between the State andthe Regions on the responsibilities of health deficits had been frequent since the birthof the NHS. However, during the 2000s European commitments made regarding thecontainment of the public debt as well as NHS regionalization saw the opportunity ofdefining a mechanism, which allowed the central government to intervene to ensurecontrol of health expenditure at regional level. This mechanism became essential in theyears of financial crisis.

45 On this purpose, the budget law for 20057 and, above all, the State-Regions Agreementof 23 March 20058 (with subsequent adjustments) defined a multi-tiered monitoringmechanism of health expenditure, debt settlement and recovery. In the event that thedeficit in the management of the RHS persisting in the fourth quarter of the financialyear surpasses some pre-defined caps (which have become stricter by 2010), the Regionis considered to be in a situation of financial imbalance. Once that the excessive deficitis definetely assessed by a monitoring unit set up by the State-Regions Conference, thePrime Minister warns the Regions to take the necessary measures to ensurerebalancing by 30 April of the following year. Within 30 days the Region had to approvea recovery plan from the operating deficit, which has to be approved by the monitoringunit and the State-Regions Conference within the subsequent 45 days.

46 If the plan has not been submitted or has been rejected by the State-RegionsConference, the Prime Minister (and the MEF) shall appoint a Commissioner to preparethe plan and its implementation. Moreover, a series of actions for the settlement of thedeficit are activated, entailing the increase of the regional taxes, a total blocking instaff hiring and turnover and the ban of undertaking non-compulsory expenditures. Incase of inertia of the Region, these measures are automatically triggered within 30 daysfrom the appointment of the Commissioner. Following the approval of the debtrecovery plan, the MEF allocates the 40% of additional resources deemed necessary forpayoff. The remaining 60% is granted on a quarterly and annual basis after assessmentof the implementation of the plan.

47 In 2007, the recovery plan was activated for seven Regions and other three were addedin 2009 and 2010. Eight over ten Regions are still subject to this mechanism. TheseRegions include all Southern and Southern-Central Regions, except the small Basilicata,while only two Northern Regions were forced to approve a recovery plan and werenever commissioned.

48 One of the most delicate and most discussed passages of the recovery plan procedurewas the appointment of a Commissioner. This role was attributed to the Governor ofthe commissioned Region itself, until this practice was banned in 2014. However,playing the role of Commissioner, even the Governor of the Region was highlyrestricted in its freedom to define health policy, being forced to implement decisionsmostly taken by the MEF and central government. Moreover, the central governmentcould also appoint Subcommissioners, chosen from persons of proven technicalcompetence in the area of health.

49 Despite differences between individual cases, the recovery plan mechanism was largelyeffective in securing a debt reduction of the Regions. Between 2009 and 2014, the deficitof the Regions involved passed from 3.5 billion to 275 million € (Corte dei Conti, 2016).However, experience has shown that, once the plan procedures began, it was extremelydifficult to abandon them. On the basis of the documentation available on the website


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of the Ministry of Health with regard to the single plans and their processes, and theinformation collected in some interviews, we can assume that this was due not only tothe presence of particularly demanding financial targets in years of economic crisis,but also to the existence of objectives beyond purely economic aspects that impactedon quality and access to services. In many cases these objectives were not easy to meet,considering that recovery plans inevitably required retrenchment policies, whichentailed severe cuts and other kind of restrictions in service provision.

50 From the point of view of the inter-governmental relations, the recovery planmechanism severely restricted the autonomy of Regional governments in thedevelopment of health policies, including those relating to service management andorganization. Central government and, in particular, the MEF, directly or by means ofthe monitoring unit of the State-Regions Conference, not only exerted a penetratingsupervision and monitoring of the plan implementations in the Regions concerned, butoften played a proactive role in defining specific measures of debt relief. Moreover,they gained the right to exert a sort of veto, in the face of Regional policies that involveincreased expenditure. Although the formal division of powers between the levels ofgovernment has not changed over the past decade, regional decentralization proved infact to be much weakened in favour of an increase of the Central State’s regulatoryrole, embodied by MEF rather than by the Ministry of Health (Frisina-Doëtter and Neri,2018a; 2018b).

51 If Central and Southern-Central health care have been subjected to these strict forms ofcontrol during the years of crisis and until now, this has not been the case of theNorthern and Central-Northern regions, except for two cases (Piedmont and Liguria).In most of these Regions, the ability to maintain fiscal equilibrium or limited deficit hasallowed them to consolidate and strengthen the autonomy of Regional health policies.Certainly, the austerity measures previously described, taken at a national level,represented constraints with which Regional governments had to come to terms with,in any part of the country. However, this did not prevent the “virtuous” Regions fromsafeguarding, substantially, their autonomy in health care management andorganization. The structural reforms of the Lombard and Tuscan health system adoptedin recent years are two examples of the clear persistence of autonomous andunchanged powers compared to the past in the organization and regulation of services,by the Regions not subject to recovery plans.

52 Moreover, some of these Regions (Emilia-Romagna, Lombardy and Veneto) haverequested “particular forms and autonomy conditions” (Article 116, clause 3, ItalianConstitution), both in the health sector and in other policy sectors, which would makethem more similar to the five Italian Regions provided, from the 1950s, with a specialautonomy for historical or ethnical reasons. This showed the will to move towards amore clearly oriented structure of powers in the federal sense.

53 After the consultative referendum held in Lombardy and Veneto on 22-23 October 2017– which saw the success of the initiative promoted by the Regional governments – andthe formal request of the Emilia-Romagna government between August and October2017, a negotiating table was opened with the central government, according to theprocedure laid down in Article 116 of the Italian Constitution. While negotiations arestill underway in 2018 and 2019, other Regions requested greater autonomy.

54 Although the contents required by the “greater autonomy” still have not beenexplicitly defined, it is quite clear that it should concern not only the management of


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resources but also regional tax capacity, today very limited, so as to take a significantstep towards a more complete accountability of the Regions. The most delicate issueconcerns the possibility to retain most of fiscal revenues collected within any singleRegion, limiting the process of central redistribution. Given the very relevantdifferences in fiscal capacity between the north and the south of Italy, the potentialeffects of this change could be highly detrimental for Southern Regions.

5. Conclusion

55 The tendency to move towards a substantial recentralization of decision-making innational health policies with relevant impact of expenditure is linked to the need torespect the restrictions imposed by the process of European integration and MonetaryUnion and the globalisation of international markets, in a situation of a severe financialcrisis. That condition has enhanced the role of central government, able to participatein decision making at supranational level and to influence economic dynamics andinternational finance, albeit with many limitations. In this sense, centralization seemsto be determined primarily by factors exogenous to the health care system, which haveto do with “external constraints” (Ferrera and Gualmini, 2004) to the Italian economicand welfare system. These constraints are not new, but in the last decade they actedwith a strength and cogency unknown in the past.

56 However, the re-affirmation of the role of the central State in the NHS depends also onfactors endogenous to the health care system, such as the characteristics andshortcomings in the NHS governance, which were emphasized by the economic crisis.As we have described, the institutional framework that emerged after the 1990s had ledto the construction of mechanism of joint policy making between the centralgovernment and the Regions based on the State-Regions Conference. This system hasshown serious limits in conditions of economic crisis. The ability of the centralgovernment, even more than the Parliament, to determine ultimately the amount ofNHS funding through legislation resulted in the affirmation of the prevalence of thislevel of government, highlighting the substantial supervision on financial resourcesfrom the centre. The imbalance in powers exercised in this field is also accentuated bysevere limitations that exist in the Regional fiscal autonomy. In addition, centralcontrol, an element often overlooked, is not limited to financial resources but extendsto the determination of the other major health sector inputs (labour, drugs, equipment,and medical devices), as highlighted by the austerity measures imposed by theGovernment in recent years.

57 These trends were not limited only to the years of financial emergency arising from thesovereign debt crisis, but were manifested, in part, already earlier and somehowseemed to continue in more recent years, favoured by the persistent state of theGovernment’s financial difficulties due to the high public debt. In this sense, we canassume that they will continue, perhaps in a milder form, even under conditions ofeconomic recovery.

58 Other factors have contributed to the re-assertion of the role of the centralgovernment, such as the overwhelming incapacity of at least half of the Regions tomanage the health system efficiently, as well as to guarantee adequate quality services,and also the legitimation crisis of the Regional institution.


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59 The story of the debt recovery plans and, at the same time, the request for greaterautonomy from Northern Regions lead us to affirm that the NHS is not directedtowards a simple re-centralization, at least in the regulation of the system, but rathertowards a search on new balances between centralization and decentralization.

60 The most probable hypothesis is that all this can lead to the end of the traditionaldistinction between five Regions provided with special autonomy and fifteen Regionsprovided with a uniform set of powers and responsibilities, in direction of a system ofpowers and responsibilities that differs according to the conditions of each Region or ofdifferent groups of Regions. On the substantive level, in fact, what happened in the last10 years represents an evolution towards different forms of decentralization orfederalism in the NHS. In the coming years, the change could find greater recognitionalso on a formal level.

61 The evolution towards a “differentiated federalism” (Frisina-Doëtter and Neri, 2018a;2018b) presents risks and opportunities for the NHS. On one hand, it responds tounquestionable territorial differences in the economic and financial resources,administrative tradition and capacity as well as population needs, which the previousNHS governance did not take into account. On the other hand, there is the serious riskthat existing territorial differences will be exacerbated, thus further widening the gapbetween the north and the south of Italy and resulting in the deflagration of the“National” Health Service. To prevent this from happening, at least two conditions areneeded. First of all, the formal attribution of greater autonomy to Northern Regionswill be devised by finding institutional and regulatory mechanisms able to ensure theprinciples of equity and solidarity which are at the base of the NHS. Second, the Statewill necessarily go beyond its current prevailing role of financial watchdog, in chargeof implementing retrenchment policies, and actively help Regions with lowerperformances improve the quality of their health services by developing innovativeforms of planning and cooperation. At the moment, both of these conditions seem farfrom being satisfied.

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Sarti, Simone (2017), “Salute e crisi: convergenze e divergenze nei sistemi regionali tra il 2005 e il2013”, Autonomie locali e servizi sociali, 2, 201-220.

Sarti, Simone; Terraneo, Marco; Tognetti, Bordogna Mara (2017), “Poverty and Private HealthExpenditures in Italian Households during the Recent Crisis”, Health Policy, 121(3), 307-314.

Sotiropoulos, Dimitri A. (2015), “Southern European Governments and Public Bureaucracies inthe Context of Economic Crisis”, European Journal of Social Security, 2, 226-245.

Terraneo, Marco (2018), La salute negata. Le sfide dell’equità in prospettiva sociologica. Milano:FrancoAngeli.

Toth, Federico (2014), “How Health Care Regionalisation in Italy is Widening the North-SouthGap”, Health Economics, Policy and Law, 9(3), 231-249.

Toth, Federico (2016), “The Italian NHS, the Public/Private Sector Mix and the Disparities inAccess to HealthCare”, Global Social Welfare, 3, 171-178.

Vicarelli, Giovanna (2015), “Healthcare: Difficult Paths of Reform”, in Ugo Ascoli; EmmanuelePavolini (eds.), The Italian Welfare State in a European Perspective. Bristol: Policy Press, 157-178.

Vicarelli, Giovanna; Pavolini, Emmanuele (2015), “Health Workforce Governance in Italy”, HealthPolicy, 119(12), 1606-1612.


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https://www.contoannuale.mef.gov.it/

https://www.contoannuale.mef.gov.it/

NOTES1. Accessed on 30.12.2018, at http://www.oecd.org/els/health-systems/health-data.htm. 2. Law Decree No. 95, 6 July 2012, converted into Law No. 135, 7 August 2012, “Conversione inlegge, con modificazioni, del decreto-legge 6 luglio 2012, n. 95, recante disposizioni urgenti per larevisione della spesa pubblica con invarianza dei servizi ai cittadini” (text available at https://www.gazzettaufficiale.it/eli/id/2012/08/14/12A09068/sg). 3. For a broader review of the austerity measures approved over the years, see the documentspublished on the website of the Chamber of Deputies (la Camera dei Deputati, one of the twobranches of the Italian Parliament), on “issues of parliamentary activity”, for the health sector,available at https://temi.camera.it/leg17/, last access on 31.12.2018. 4. Law Decree No. 78, 31 May 2010, converted into Law No. 122, 31 July 2010, “Conversione inlegge, con modificazioni, del decreto-legge 31 maggio 2010, n. 78, recante misure urgenti inmateria di stabilizzazione finanziaria e di competitivita' economica” (available at https://www.gazzettaufficiale.it/eli/id/2010/07/30/010G0146/sg). 5. Law Decree No. 98, 6 July 2011, converted into Law No. 111, 15 July 2011, “Ripubblicazione deltesto del decreto-legge 6 luglio 2011, n. 98 (in Gazzetta Ufficiale – Serie generale – n. 155 del 6luglio 2011), convertito, con modificazioni, dalla legge 15 luglio 2011, n. 111, (in Gazzetta Ufficiale– Serie generale – n. 164 del 16 luglio 2011), recante: ‘Disposizioni urgenti per la stabilizzazionefinanziaria’” (available at https://www.gazzettaufficiale.it/eli/id/2011/07/25/11A10000/sg). 6. Law No. 42, 5 May 2009, “Delega al Governo in materia di federalismo fiscale, in attuazionedell’articolo 119 della Costituzione” (available at https://www.gazzettaufficiale.it/eli/gu/2009/05/06/103/sg/pdf). 7. Law No. 311, 30 December 2004, “Disposizioni per la formazione del bilancio annuale epluriennale dello Stato (legge finanziaria 2005)” (available at https://www.gazzettaufficiale.it/eli/id/2004/12/31/004G0342/sg). 8. Conferenza Permanente per i Rapporti tra lo Stato, le Regioni e le Province Autonome diTrento e Bolzano, 23 March 2005, “Intesa, ai sensi dell'articolo 8, comma 6, della legge 5 giugno2003, n. 131, in attuazione dell'articolo 1, comma 173, della legge 30 dicembre 2004, n. 311”(available at https://www.gazzettaufficiale.it/eli/id/2005/05/07/05A03665/sg).

ABSTRACTSThis essay analyses the evolution of the National Health Service (NHS) in Italy after the beginningof the financial crisis of 2008, focusing on some trajectories of change underway in the NHSgovernance. It starts with a reconstruction of the economic and financial framework of the NHSin the last 10 years, briefly describing the austerity policies implemented in the health sector. Itthen outlines the NHS institutional framework as it emerged from 1990s reforms, which is basedon intergovernmental relations and joint policy-making between the State and the Regions. Inthe third part, it shows how the response to the economic crisis has had a significant effect onthese relations, triggering a transformation in the NHS governance. This change, which is farfrom being concluded, could seriously undermine the universalistic nature of the Italian NHS andits ability to pursue the values of equity and solidarity, especially at a territorial level.


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https://temi.camera.it/leg17/

https://temi.camera.it/leg17/

https://www.gazzettaufficiale.it/eli/id/2010/07/30/010G0146/sg






https://www.gazzettaufficiale.it/eli/gu/2009/05/06/103/sg/pdf










Este artigo analisa a evolução do Serviço Nacional de Saúde (SNS) na Itália após o início da criseeconómica de 2008, focando-se em algumas das trajetórias de mudança ocorridas sob agovernança do SNS. Aborda, inicialmente, a reconstrução da estrutura económica e financeira doSNS nos últimos 10 anos, descrevendo brevemente as políticas de austeridade implementadas nosetor da saúde. De seguida, delineia a estrutura institucional do SNS a partir das reformas dosanos 1990, que se baseiam nas relações intergovernamentais e na formulação conjunta depolíticas entre o Estado e as regiões. Na terceira parte, mostra como a resposta à crise económicateve um efeito significativo nestas relações, desencadeando uma transformação na governançado SNS. Esta mudança, longe de estar concluída, pode comprometer seriamente a naturezauniversalista do SNS italiano e a sua capacidade para seguir os valores de equidade esolidariedade, especialmente a nível territorial.

INDEX

Palavras-chave: crise económica, cuidados de saúde, descentralização, governança, ServiçoNacional de SaúdeKeywords: decentralization, economic crisis, governance, health care, national health service

AUTHOR

STEFANO NERI

Dipartimento di Scienze Sociali e Politiche, Università degli Studi di MilanoVia Conservatorio, 7, 20122 – Milano, [email protected]


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Access to Healthcare and the GlobalFinancial Crisis in Italy: A HumanRights PerspectiveAcesso a cuidados de saúde e a crise financeira global em Itália: uma perspetivados direitos humanos

Rossella De Falco

EDITOR'S NOTE


1. Economic Crisis and Health Systems: An Overview

In 2008, the United States subprime mortgage market entered a financial crisis,triggering one of the most severe global recessions since the 1930s. At first, policy-makers around the world unanimously carried out conventional countercyclical fiscalpolicies, increasing spending and rising taxes to revive aggregate demand. Supportedby the International Monetary Fund (IMF) 37 countries (accounting for around 73% ofthe world) expanded public spending, resulting in an annual Gross Domestic Product(GDP) growth of 3.3% (Blanchard, 2008; Ortiz et al., 2015). However, this also increasedpublic debts. As a consequence, many governments turned to harsh austerity measuresto restore public finances, either out of their own volition or under pressure fromregional banks and international financial institutions (IFIs). Even if the rise in publicdeficits was largely a result of the crisis, the international community began looking atwelfare states with suspicion, blaming overly generous welfare benefits for the globalfinancial meltdown (ibidem). In this way, policies such as horizontal budget cuts,regressive reforms and large-scale privatisation became the new normal in policy-


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making circles, causing widespread socio-economic malaise in developed and non-developed countries alike (Chakrabortty, 2016). Austerity measures can also result insocioeconomic rights’ backsliding, with the most vulnerable groups bearing theheaviest burden of fiscal adjustment. In these particularly severe cases, economicrecovery policies might constitute a prima facie violation of the International Covenanton Economic, Social and Cultural Rights – ICESCR (United Nations, 1967).

As many other fundamental rights, the right to health has been sternly affected byregressive fiscal measures. This is not surprising, as healthcare often occupies a hugeshare of public expenditure in most welfare states, and many governments reducedtheir health budgets (Mackenbach, 2013). This policy pattern was followed by theItalian government as well, with huge repercussions on healthcare accessibility. In fact,if progressive health policies, combined with inclusive social policies, can improvehealthcare affordability, horizontal cuts might hinder equitable access to care (Sabine,2016). Consistently, several waves of austerity undertaken by the Italian governmentare associated with an increase in unaffordable healthcare in Italy. For example,according to a medical association’s report, in 2015, 12.2 million Italians, or one in five,went without medical care, while 7.8 million spent all their saving on healthcare orcontracted a medical debt (CENSIS/RBM, 2018). In other words, the United NationsCommittee on Economic, Social and Cultural Rights is fully backed by hard evidencewhen it expresses serious concerns over the enjoyment of the right to health in Italy(United Nations, 2015).

This paper analyses how the regressive fiscal measures that followed the 2008’s globalfinancial crisis exacerbated inequities in access to care throughout Italy. Thus, thiswork points out to a potential backsliding in the enjoyment of the right to health,which Italy recognises not only by being a member of the ICESCR, but also througharticle 32 of its Constitution (Italian Republic, 1947). To this end, disaggregatedEuropean Union Statistics on Income and Living Conditions (EU-SILC) microdata onunmet medical needs will be scrutinised in detail, highlighting how disparities inaccessing care have widened during the crisis. These data are disaggregated by socio-economic status, labour status, education attainment level as well as country ofcitizenship and of birth. Special attention will be also given to geographical differencesbetween Italian regions.

Austerity is not the only alternative when it comes to economic recovery. Moreover,the negative effect of austerity on economic output and long-term unemployment havebeen widely discussed by heterodox and orthodox economists alike (Krugman, 2015;Stiglitz apud Hackwill, 2016). Bearing this in mind, the conclusions of this work willsummarise the potential alternatives to austerity available to the Italian government,while also analysing the conduct of the Italian government in light of its human rights’obligations.

2. Inequality, Access to Care and Health Inequities atTimes of Economic Crisis: a Human Rights Framework

Equitable access to healthcare is one of the tenants of the right to the highestattainable standard of physical and mental health. In fact, article12 of the ICESCRobliges member states to take steps towards “the prevention, treatment and control ofepidemic, endemic, occupational and other diseases” as well as “the creation of


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conditions which would assure to all medical service and medical attention in the eventof sickness” (United Nations, 1967: 6-7). Equitable access to healthcare, thus, isdependent upon the dimensions of availability and accessibility of healthcare goodsand facilities (United Nations, 2000). Availability relates to the existence of healthcarefacilities and essential medicines in proper quantity and of acceptable quality (ibidem).Accessibility, instead, is a multidimensional principle composed of the followingelements: physical accessibility; economic accessibility (i.e. affordability); non-discrimination; and information accessibility.1 In Europe, the warranty of fair anduniversal access to high-quality and timely healthcare is also provided by the Charterof Fundamental Rights of the European Union (European Union, 2012) and theEuropean Social Charter (Council of Europe,1996).

Notwithstanding the plethora of norms ensuring access to care, barriers in accessinghealthcare are widespread across European countries. This is concerning, as equitableaccess to care is a key factor in preventing health inequities. In fact, if the promotion ofthe underlying determinants of health diminish socio-economic disparities incontracting an illness, enabling access to health eases inequities in surviving andhealing from diseases (Costa, 2017). Therefore, to ensure the progressive realisation ofthe right to health and to combat health inequities, it is urgent to ensure that allindividuals have universal access to timely care, with special attention to vulnerablegroups.

Which factors cause inequality in accessing care? First, high levels of income inequalitywithin socio-economic groups can result in massive health inequities. In fact, peopleliving in poverty, or experiencing precarity on low-paid jobs, might forego care due tofinancial reasons. In “The Killing Fields of Inequality”, Therborn (2012) defines thesekinds of socio-economic disparities as inequality “of resources”. Likewise, individualdifferences such as age, gender, nationality and country of birth can all generatesignificant gaps when accessing healthcare. These inequalities are defined as“existential” by Therborn (ibidem). Finally, regressive health policies might alsoundermine equitable access to care. For example, the 2008’s global financial crisis hasprompted an increase of people lamenting unmet healthcare needs in the EU (Baeten etal., 2018). This might be the result of the harsh austerity measures implemented inEurope after the global recession, with loss of entitlements for some groups and, at thesame time, a higher need for healthcare due to the crisis (De Vogli, 2013, 2014;Loughane et al., 2019).

3. Methodology

This paper investigates the vicious mechanism between austerity policies, structuralinequalities and access to care through the case-study of a high-income Mediterraneancountry: Italy. In fact, Italy was hardly hit by the economic crisis, with severerepercussions on its healthcare system. After depicting the major healthcare reformsthat followed the global financial crisis, inequitable access to healthcare is analysedthrough descriptive statistics. The key indicator used is “unmet needs for medical care”by reason, disaggregated by income quintile, labour status, educational attainment,country of birth and citizenship. This microdata is collected yearly by Eurostat withinthe EU-SILC survey, and they are freely accessible at aggregate level. Special attentionwill be given to the effect of being either a poor or a working poor on accessing


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healthcare. For the individuals that are excluded from official data, such as illegalmigrants, qualitative data will be used. As for data regarding geographical healthinequities, the point of reference is the Italian National Statistics Office’s databaseHealth for All.2

As regards the theoretical premises underpinning the present work, this article buildson the vast literature on human rights measurement (Barsh, 1993; Landman andCarvalho, 2009; Ramirez, 2011; Hunt et al., 2013) as well as health equity (Diderichsen etal., 2001).

4. The Italian National Health Service (NHS): A Systemunder Threat

The Italian NHS (Servizio Sanitario Nazionale – SSN) was founded in 1978, replacing thepre-existing social health insurance system. Based on the principles of universality,solidarity and financial protection, the system is funded by general taxation andprovides automatic coverage to all citizens, legal foreign residents and migrantsholding a residence permit. Thus, the institution of the Italian NHS realised, inprinciple, both the collective and the individual dimensions of the right to health, asenshrined by article 32 of the Italian Constitution. In fact, this article warrants that theright to health is “a fundamental right of the individual” as well as a “collectiveinterest”, enabling “free medical care to the indigent” (Constitution of the ItalianRepublic, 1947, art. 32).

For years, this three-tiered system has delivered free, high-quality healthcare to thosein need, gaining its position as the second best in the world in the WHO ranking (WHO,2000). Of course, much room of improvement existed, as testified by the unsolved gapbetween Northern and Southern regions, combined with financial constraints plaguingthe most vulnerable groups. However, subsequent reforms focused more on costcontainment rather than easing health inequities. In fact, only ten years after the SSNwas founded, user fees were introduced aside general taxation as an instrument toregulate healthcare demand and increase the efficiency of the system (Decree-Law382/1989).3 By the same token, potential measures that impinged on health equity wereintroduced with law 347/2001,4 which established that single Italian regions can setdifferent rules on user fees due to budget reasons. The gradual shift of health costsfrom the state to the individual has been further aggravated by the introduction of anadditional fee on specialist visits (Decree-Law 111/2011;5 Cittadinanzaattiva, 2011). Thisis worrying, as raising user fees imply a trade-off between efficiency and equity (Rebba,2009), threatening universal access to affordable healthcare. 4.1. The 2008’s Great Recession and Austerity: A GlobalPhenomenon

Before proceeding with the analysis of Italian health reform policies, it is necessary tolink Italy’s decisions in policy making with the broader global turn towards spendingcontraction. Since 2010, in fact, most governments around the world have beenimplementing harsh austerity policies to achieve fiscal consolidation (Ortiz et al., 2015).According to a recent estimate of the International Labour Organization (ILO), in 2018,124 countries will be adjusting expenditures in terms of GDP; the number is expected to


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rise slightly in 2020 (Ortiz et al., 2015: 2-6). This short-term adjustment process issupposed to affect nearly 80% of the global population (ibidem). Moreover, by 2020, anestimated 30% of countries in the world will be undergoing excessive fiscal contraction,defined as cutting public expenditures below pre-crisis levels, including countries withhigh developmental needs such as Angola, Eritrea, Iraq, Sudan and Yemen (ibidem).

As shown in Table 1, contractionary fiscal policies can be implemented either byreducing spending or increasing revenues. Measures aimed at reducing spendinginclude budget cuts, regressive tax changes, labour reform and pension reform.Although less often implemented, outsourcing and privatisation have also been used bygovernments as a way of collecting short-term revenues and decreasing public deficits(Chakrabortty, 2016). TABLE 1 – Major Fiscal Consolidation Measures Implemented or Under Consideration Worldwide

Reducing Spending Collecting Revenues

- Eliminating or reducing subsidies

- Wage bills cuts/caps

- Rationalizing and further targetingsocial safety nets

- Healthcare reforms

- Old-age pensions reforms

- Increasing taxes on goods and services (mostly Valueadded Taxes – VATs)

- Privatisation of Public Services

Source: Elaboration by the author from Ortiz et al. (2015: 12-14) and CESR (2018: 14-15).

In line with this global retrenchment in public spending, health expenditure in Italyalso began decreasing over the period 2008-2010. At the same time, as shown in Figure1, private healthcare spending started increasing. This shift in public and privateshares of healthcare costs will be now analysed in detail over the next paragraphs.


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FIGURE 1 – Public (GDP, %) vs. Private Healthcare Spending (Current Health Expenditure – CHE, %),Italy

Source: Elaboration by the author from OECD – Organisation for Economic Co-operation andDevelopment (2019), “OECD Health Statistics 2019”, July 2. Accessed on 23.05.2019, at http://www.oecd.org/els/health-systems/health-data.htm.

4.2. The Economic Crisis in Italy and the Adoption of AusterityMeasures

Italy’s economic growth was already stagnant when the sovereign debt crisis struck theEurozone. Additionally, Italy’s public debt grew from 103% in 2007 to nearly 127% in2012 (Petrelli, 2013). This escalation of the public debt compromised mutual trustbetween banks, dumping sovereign bond markets’ confidence in Italy’s recovery(ibidem). The consequent credit freeze pushed the country into a long-lasting recession,with widespread bankruptcies and companies’ default (ibidem). Swiftly, the fear ofcontagion spread among the other major European economies. In fact, if the thirdlargest European economy ended like Greece, the stability of the whole Eurozone wouldhave been severely compromised.

On 5 August 2011, the Italian government received a letter by European Central Bank’sleaders Mario Draghi and Jean-Claude Trichet. The letter was an offer of debt financingby the European Central Bank (ECB), given the implementation of the followingreforms: large-scale privatisation; transferring of collective bargaining toundertakings; public sector pay-cuts; privatisation of public utilities; introduction ofautomatic correction mechanisms for deficits (Fischer-Lescano, 2014). Therefore, Italy’simplementation of austerity policies was not the result of direct economicconditionalities attached to international rescue loans, as in the case of theMemorandum of Understandings (MoUs) signed by Greece with the institutions of theTroika (IMF, World Bank, and the ECB). Rather, Italy reacted to an open letter by theECB. The letter was made public by several newspapers, but it was not intended as anofficial document (Corriere della Sera, 2011). Because of the letter, then-Prime MinisterSilvio Berlusconi resigned. Soon after, in 2011, a bipartisan governmental coalition


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guided by the renowned academic and economist Mario Monti implemented a series ofpolicy actions aimed at avoiding a Greek-style public debt collapse in Italy. 4.3. Italian Austerity Policies in the Field of Healthcare (2010-2016)

FIGURE 2 – Public Health Expenditure (%, GDP), Italy (2008-2018)


Over the 2008-2010 period, Italy froze public spending on health. In fact, the averageannual growth of health spending was 6% between 2000 and 2007, but only 2.3% overthe period 2008-2010 (La Repubblica, 2013). As shown in Figure 2, in 2010, Italian healthspending abandoned its decennial positive trajectory and began a gradual, yet steady,decrease (DEF, 2017). At the same time, funds for essential medicines and the NationalHealth Fund were reduced, amounting to an overall budget cut of €4.15 billion in 2012.6

Co-payments for outpatient drugs and prescribed procedures/specialist visits (Gabriele,2015) have also grown by 53.7% (real terms) over the 2007-2015 period (CENSIS/RBM,2018). In this context, funds for guaranteed free pharma decreased by 660 million,while expenditure for hospitals by 880 million (ibidem). Additionally, the ItalianMinistry of Economics and Finance has recently predicted that health spending willfurther diminish over the period 2018-2020, slumping as low as 6.4% of the GDP (DEF,2017). This is even more concerning when comparing Italian levels of public healthspending with those of the rest of Europe. In fact, Italy performs far worse thancountries of comparable GDP size, such as France and Germany (OECD, 2016).

4.4. The Impact on Healthcare Accessibility and Availability

The austerity measures implemented by the Italian government in the field ofhealthcare have impacted multiple dimensions of the right to health: accessibility,availability, quality and acceptability. As this paper is concerned with equitable accessto care, only the dimensions of accessibility and availability of healthcare will be


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analysed. Therefore, below it will be analysed how austerity measures impacted: out-of-pocket payments (OOPs); healthcare facilities; waiting lists.

4.4.1. Out-of-Pocket Payments

OOPs are direct payments made by individuals to healthcare providers. High levels ofOOPs might create an access barrier and put affordability of healthcare at risk. As such,they represent a human rights indicator that pictures well the level of affordability ofhealthcare systems. Empirical research has also shown that, at global level, the less agovernment spend on health, the more the healthcare system tends to rely on OOPs(McIsaac et al., 2018).

FIGURE 3 – Reliance on Out-of-Pocket Payments vs Government Spending on Health (%, GDP), Italy,(2007-2017)


As Figure 3 shows, after the implementation of the first round of austerity measures(2010), user fees (OOPs) as a percentage of current health spending begun rising,showing a negative correlation to the decrease in the governmental share. After sixyears of fiscal contraction, the percentage of OOPs reached 23%, or one fifth of theoverall expenditure on health (OECD and European Observatory on Health Systems andHealth Policies, 2017). As a way of comparison, in 2014, Italian user fees and co-payments resemble the ones in Greece and Spain, being above EU’s average anddoubling those of France. This is clearly shown in Figure 4.


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FIGURE 4 – Public Health Expenditure, % of GDP, Selected European Countries (2014)

Source: Elaboration by the author from: OECD – Organisation for Economic Co-operation andDevelopment (2019), “OECD Health Statistics 2019”, July 2. Accessed on 23.05.2019, at http://www.oecd.org/els/health-systems/health-data.htm.

4.4.2. Waiting Lists

According to the European Social Policy Network (ESPN), long waiting times are acommon source of discontent among all European citizens. Excessively long waitingtimes can also foster inequities in accessing care, as high-income patients tend tobypass waiting lists in the public sector by consulting a private specialist, payingadditional fees (Baeten et al., 2018). Likewise, informal, under-the-table payments are acommon practice in several European countries (ibidem).

On a similar pace, excessive waiting lists have been widely documented throughoutItaly by independent agencies (CENSIS/RBM, 2018). However, states have startedcollecting data on waiting lists only recently. Therefore, a systematic diachronicanalysis is not possible in this case. As it can be seen from Table 2 and Table 3, in anycase, average waiting times (in days) have been rapidly growing over the 2014-2017period, according to an independent investigation by CENSIS/RBM (ibidem). Table 3 alsoshows different waiting times for private and public facilities, unveiling hugediscrepancies. This data, however, have the limitation of coming from a report of twoprivate entities (RBM7 and Censis8), rather than from a peer-reviewed academic journal,or official statistics. Therefore, they have to be taken with a grain of salt. TABLE 2 – Waiting Times (in Days) National Average, by Type of Visit, Selected Years

2014 2015 2017


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Oculist Visit 61,3 62,8 88,3

Orthopaedical Visit 36,4 42,6 55,6

Colonoscopy 69,1 78,8 96,2

Source: Elaboration by the author from CENSIS/RBM (2018: 54).

TABLE 3 – Waiting Times (in Days), National Averages, by Type of Visits, Public vs Private Sector

Public Private

Gastroscopy 88,9 10,2

Colonoscopy 96,2 10,2

Echocardiography 70,3 5,9

Electromyography 62,2 6,2

Source: Elaboration by the author from CENSIS/RBM (2018: 54).

4.4.3. Healthcare Facilities: Hospitals and Hospital Beds

Shortages of healthcare facilities can result in increased waiting times for treatment orcosts associated to travel longer distances. This is a risk for Italy, where both hospitalsand hospital beds have been significantly downsized during the crisis. In fact, hospitalswent from 1.271 in 2007 to 1.115 in 2015 (OECD, 2018a), with a total loss of 156 hospitals.At the same time, hospital beds per 1000 inhabitants went from 3.9 in 2007 to 3.2 in2017. In Italy, however, this negative trend, however, initiated far before the crisis.9

4.5. Impact on Access to Healthcare: Widened Inequities

Horizontal budget cuts had a substantial impact on access to healthcare. However, theimpact has been far more severe for the more disadvantaged groups in the Italiansociety, whereas those that were already better-off were barely touched from the crisisregarding their access to healthcare. This section investigates in detail how differencesin terms of socioeconomic, labour, education attainment status and country of originare associated with lower or higher healthcare access barrier.

4.5.1. Socioeconomic Status

Financial barriers, such as user fees and co-payments, constitute a serious concern forlower income groups. Moreover, medium and low-income patients face severe barriersin accessing healthcare timely when the public sector is plagued by excessively longwaits (Landi, 2013; Petrelli et al., 2012). Bearing this in mind, this section explores howsocioeconomic status can determine unequal access to healthcare at times of crisis.


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As Figure 5 shows, the impact of regressive fiscal consolidation measures has beenunevenly distributed across income groups over the 2008-2017 period. FIGURE 5 – Unmet Needs for Medical Care, “Too Expensive, Too Far to Travel or Waiting List”, byIncome Quintile (% of the total population), Italy, 2008-2017

Source: Elaboration by the author from Eurostat, “European Union Statistics on Income and LivingConditions (EU-SILC)”. Accessed on 23.05.2019, at https://ec.europa.eu/eurostat/web/microdata/european-union-statistics-on-income-and-living-conditions.

As it can be seen in the figure above, since the start of the crisis, the percentage ofpeople in the lowest quintile suffering from unmet medical needs had been steadilygrowing, becoming as high as 15.5% in 2015. By contrast, the number of people in thehighest quintile reporting foregone care was below 1% over the period 2008-2017 and ithas also diminished during the period of the crisis. Clearly, the most vulnerable socio-economic group was bearing the heaviest burden of contractionary fiscal policies.Reinforcing this evidence, a recent study has yielded that, in Italy, people that are atrisk of poverty or experience severe material deprivation are more likely to renounceto healthcare (Gaudio et al., 2017). Moreover, the likelihood is higher for people livingin the Islands, in the South and for foreigners (ibidem).

TABLE 4 – Unmet Needs for Dental Care, “Too Expensive”, (%), Difference between Pre and PostCrisis Levels – Low-Income vs High-Income Earners

2008 2016 Difference

Bottom 20% 14.6 17.5 + 2.9%

Top 20% 3.2 2.7 - 0.5%


Unmet needs for dental care show a similar pattern as shown in Table 4 and Figure 6. InTable 4, it can be seen that unmet needs for dental care due to financial reasons rose by


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almost 3% for the poorest income quintile, while they even reduced by 0.5% for thebetter-off.

FIGURE 6 – Unmet Needs for Dental Care, ‘Too Expensive, Far to Travel or Waiting List’, by IncomeQuintile, Italy, % of Total Population


Figure 6, instead, shows unmet needs for dental care due to all reasons over time. Thefigure shows that, in 2008, 14.6% of the Italians in the poorest quintile could not afforddental care, reaching 20.1% in 2014 and remaining high, at 17.5%, in 2016. Differently,the top earners self-reported no significant increase during the years of the crisis.Special attention should be given to old people, who are particularly affected by accessbarrier for dental care. In fact, according to a report by the Italian National StatisticsOffice, only 29.2% of people aged 75+ accessed dental care in 2015, against the Europeanaverage of 45.3% (ISTAT, 2015a).

4.5.2. Employment Status

The employment status can also determine inequalities in accessing care. For example,the growth in occupational health insurance coverage may increase inequalities inaccess to healthcare; this because the amount of occupational welfare benefits dependsstrongly on companies’ characteristics such as size and productivity and can galvanizehealth inequities when it comes to access healthcare services (Baeten et al., 2018).Troublingly, voluntary and occupational health insurance may also lead to shortage ofpublic healthcare, as they encourage NHS’ doctors to join the private sector (ibidem).


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FIGURE 7– Unmet Needs for Healthcare, “Too Expensive, Far to Travel or Waiting List”, Unemployedvs Employed Persons, % of people aged 55 to 64, 2008-2017, Italy


Figure 7 displays that, during the crisis, the proportion of Italian unemployed peopledeclaring unmet medical needs is much higher than employed persons. For example, in2008, unmet medical needs for unemployed people aged 55-64 were three times higherthan those of employed ones. This inequality has widened over time the period2008-2017, with employed people showing only a minor increase.

4.5.3. Educational Attainment

The level of education can hugely influence access to care too. For example, lack ofinformation and social networks can limit the auto-detection of severe illnesses. It hasbeen proven, in fact, that for lack of knowledge, marginalisation and lack of socialsupport’s networks can delay essential surgical operations such as hip replacement orcataract (Petrelli et al., 2012).

TABLE 5 – Unmet Needs for Medical Care, “Too Expensive, Far to Travel or Waiting List”, by Level ofEducational Attainment, (%),2014, Italy

TotalMedicalcare

Dentalcare

Mentalhealthcare

Prescribedmedicines

People with Primary Level ofEducation or Less

19,9 14,6 17,9 3,7 8,9

People with Tertiary Level ofEducation

10,5 7,4 8,8 2,6 4,5


Table 5 summarises EU-SILC survey data for 2014, disaggregated by level of educationattainment. Individuals with lower levels of education lament higher unmet medicalneeds in comparison to those that accomplished higher levels of education, such as a


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university degree. Under EU-SILC, the education attainment levels of surveyrespondents are classified according to the 'International Standard Classification ofEducation', version of 2011 (UIS, 2012), so that data are harmonised for comparisonbetween different countries.10

4.5.4. Country of Citizenship

The Italian NHS offers free medical care to all legal residents and migrants holding apermit.11 However, Italian citizens and foreigners access healthcare differently,according to Eurostat’s data. As it is shown in Figure 8, these differences widenedthroughout the crisis, skyrocketing in 2015, while remarkably easing in 2017.

FIGURE 8 – Unmet Needs for Medical Care, by Citizenship, “Too Expensive, Far to Travel or WaitingList”, (%), Italy


Similar trends are observed when looking at the country of birth, rather thancitizenship. In fact, access barriers lamented by those being born in another countryare on average higher with respect to those having a different citizenship. These trendsare shown for years 2008-2017 in Figure 9.


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FIGURE 9 – Unmet Needs for Medical Care, by Country of Birth, “Too Expensive, Far to Travel orWaiting List”, (%), Italy


Potential barriers in accessing healthcare services by the migrant population may berelated to cultural differences, communication problems, administrative barriers aswell as the personal inclinations of the health staff (Hernandez-Quevedo, 2012).

Within those people not having an Italian citizenship or not being born in Italy, thereare some groups that are totally excluded from public health services, and that do notfigure in officials’ statistics. This is the case of the migrants not holding a residencepermit, who are being increasingly marginalised, facing extremely high costs in termsof morbidity and mortality. There are also some migrants that hold a residence permitbut live in marginalised areas in the suburbs of a metropolis or in rural, semi-abandoned areas due to an incomplete inclusion process. This is especially common inthe case of “economic” migrants (MSF, 2018). According to a leading medical non-governmental organization (ibidem), these individuals are deprived not only of theright to healthcare, but also of access to proper shelter, water, sanitation and food(Camilli, 2018).

By the same token, another group of people that is particularly exposed to health risksand access barrier are the Roma and Cinti ethnic minorities. Although these peoplehave legal access to the services, strong barriers remain when it comes to the use oftheir right to timely health care (European Commission, 2004). For all these minoritiespresent on the Italian territories, the economic crisis represents a source of concernbecause of the populist parties, which ride the wave of popular discontent andgalvanise discourse of hate against foreigners in Italy. 4.6. Geographical Health Inequities: The North-South Gap

In 2006, the Italian NHS was destabilised by the growing public deficits of manyregional systems. To avoid widespread financial failure, the government requiredoverspending regions to adopt and implement formal recovery plans – Piani di Rientro(De Belvis et al., 2012). Since 2007, 10 out of 21 regions ran these plans, being requiredto address the structural determinants of healthcare costs in their territories.12

Combined with successive austerity measures, this fragmentation of the Italian NHS


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might play a substantial role in explaining the geographical health inequities (ISTAT,2015b). In fact, many districts in the South, as well as some in the rest of Italy, arestruggling to meet the minimum levels of assistance (LEAs) guaranteed by law(Grazzini, 2018). The percentage of people satisfied with healthcare treatmentsembodies the gap between Northern and Southern regions in Italy. For example, in2013, 65.3% of people in the South declared they were satisfied of their last specialistvisit, against the 77.2% in the North (ISTAT, 2015b). The gap widens consistently whenlooking at satisfaction for sanitation services inside hospitals, with 51% of thepopulation in the North being satisfied in 2012, and only 16.9% of people in the South.These trends are displayed in Figure 9. In Figure 10, instead, similar trends can beobserved regarding the satisfaction from medical and nursery assistance duringhospitalisation (ibidem).

FIGURE 10 – People Satisfied with Hospitals’ Sanitation, North-South Divide, Italy (%)

Source: Elaboration by the Author from ISTAT, Annual Report (ISTAT, 2015b)

FIGURE 11 – People Satisfied by Medical Assistance during Hospitalisation, North-South Divide (%)

Source: Elaboration by the Author from ISTAT, Annual Report (ISTAT, 2015b)


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These differences can be also seen through health expenditure per capita. In Table 6, itcan be seen that health expenditure per capita in the Northern regions are higher thanin Southern ones. Moreover, Table 6 shows that this indicator has increased over the2008-2016 period in the North. By contrast, it diminished in the South, even if slightly.

TABLE 6 – Current Health Expenditure Per Capita (in euros), North-South Comparison, 2008-2016,Italy

2008 2016

North of Italy 1794.62 1868

South of Italy 1780.69 1778

Source: Elaboration by the Author from ISTAT, Annual Report (ISTAT, 2015b).

5. Conclusions

This paper has shown that healthcare access had diminished over the 2008-2017 periodin Italy. Furthermore, disadvantaged groups also lament higher levels of unmet medicalneeds when disaggregating by: socioeconomic, labour and educational attainmentstatus; country of citizenship and origin; age; geographical provenience. Draconianausterity measures, thus, are threatening the enjoyment of the right to health in Italy.In effect, austerity measures can amount to deliberative retrogressive measures,potentially breaching a country’s obligations in respecting the socioeconomic rights ofits citizens (Bilchitz, 2014; Salomon, 2015).

According to human rights law, austerity measures, resulting in severe socioeconomicrights’ backsliding, are permitted only if they are the last resort (Bilchitz, 2014).However, austerity is far than unavoidable. The negative effect of austerity on long-term output and employment levels been widely discussed by heterodox and orthodoxeconomists alike (Stiglitz apud Hackwill, 2016; Krugman, 2015). In Europe, the cases ofcountries such as Iceland, Switzerland and Portugal (after 2013) show how economicrecovery can be realised in line with international human rights law, withoutrenouncing to efficiency and financial viability.

Looking at the Italian economy, alternatives to austerity to reduce the debt-to-GDPratio or to boost revenues include: financing at least a segment of the sovereign debtthrough bank loans, instead of financial markets’ lending (Werner, 2014); combatingfiscal evasion, increasing the progressivity of the Italian taxation system, shelteringlow and middle-income households from the worst impacts of the crisis. Thus, if manyalternatives to harsh regressive measures do exist, it might be that some of theeconomic recovery policies undertaken by the Italian government were anotherdeliberate “assault on universalism” (McKee and Stuckler, 2011: 1).


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NOTES1. These are two of the four dimensions composing the AAAQ (acceptability, availability,accessibility and quality) Framework for the right to health designed by the United NationsCommittee on Economic, Social and Cultural Rights in its General Comment 14 (UN – CESCR 2000)2. Health for All, Italy, software freely available at https://www.istat.it/it/archivio/14562.Accessed on 01.12.2019.3. Decree-Law 382/1989, “Disposizioni urgenti sulla partecipazione alla spesa sanitaria e sulripiano dei disavanzi delle unita' sanitarie locali (GU Serie Generale n.277 del 27-11-1989)”.Accessed on 01.12.2019, at https://www.gazzettaufficiale.it/eli/id/1989/11/27/089G0457/sg. 4. Decree-Law 347/2001, "Interventi urgenti in materia di spesa sanitaria". Accessed on01.12.2019 at http://www.parlamento.it/parlam/leggi/decreti/01347d.htm.5. Decree-Law 111/2011, “Conversione in legge, con modificazioni, del decreto-legge 6 luglio2011, n. 98 recante disposizioni urgenti per la stabilizzazione finanziaria (11G0153) (GU SerieGenerale n.164 del 16-07-2011)”. Accessed on 02.12.2019, at https://www.gazzettaufficiale.it/eli/id/2011/07/16/011G0153/sg. 6. See Stability Law 228/2012, “Disposizioni per la formazione del bilancio annuale e pluriennaledello Stato (Legge di stabilita’ 2013)” (12G0252) (GU Serie Generale no. 302 del 29-12-2012 – Suppl.Ordinario no. 212). Accessed on 01.01.2019, at http://www.gazzettaufficiale.it/eli/id/2012/12/29/012G0252/sg.7. For information on the insurance company RBM, please see: http://www.finmeccanica.rbmsalute.it/chi-siamo-eng.html (last accessed on 02.12.2019). 8. For information on the Social Research Foundation Censis, please see: http://www.censis.it/(last accessed on 02.12.2019).9. For OECD data on Hospital Beds, see: https://data.oecd.org/healtheqt/hospital-beds.htm (lastaccessed on 02.12.2019). Indicator Name: OECD (2019), Hospital beds (indicator). DOI:10.1787/0191328e-en 10. Metadata for the EU-SILC survey is available at: https://ec.europa.eu/eurostat/cache/metadata/en/ilc_esms.htm#meta_update1508767944514 (last accessed on 02.12.2019).11. This was disciplined by Law 40/1998 on migration.12. Piemonte, Liguria, Abruzzo, Molise, Campania, Lazio, Puglia, Calabria, Sicilia and Sardegna.

ABSTRACTSEquitable access to healthcare is fundamental in preventing health inequities, and it is warrantedby international and regional norms on socio-economic rights. However, during financial crisis,pro-cyclical fiscal austerity can shift the cost of healthcare from the public onto the individual,impinging on the right of everyone to access timely and affordable healthcare. This articleanalyses this process through the case study of Italy, where the 2008 Great Recession catalysed aseries of draconian budget cuts in the health sector. Using disaggregated survey data on self-reported unmet needs for healthcare, it will be shown that increased user fees and downsizedhealth staff and facilities, combined with reduced disposable income, was associated with adrastic rise in inequities in accessing healthcare in Italy.


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http://www.parlamento.it/parlam/leggi/decreti/01347d.htm

http://www.parlamento.it/parlam/leggi/decreti/01347d.htm





http://www.gazzettaufficiale.it/eli/id/2012/12/29/012G0252/sg




http://www.finmeccanica.rbmsalute.it/chi-siamo-eng.html




http://www.censis.it/

http://www.censis.it/

https://data.oecd.org/healtheqt/hospital-beds.htm

https://data.oecd.org/healtheqt/hospital-beds.htm

https://ec.europa.eu/eurostat/cache/metadata/en/ilc_esms.htm#meta_update1508767944514




O acesso equitativo aos cuidados de saúde é fundamental na prevenção das injustiças na saúde e égarantido por normas internacionais e regionais sobre direitos socioeconómicos. No entanto,durante uma crise financeira, a austeridade fiscal pró-cíclica pode transferir o custo dos cuidadosde saúde do público para o indivíduo, afetando o direito de todos ao acesso adequado a cuidadosde saúde. Este artigo analisa este processo através do estudo de caso da Itália, onde a GrandeRecessão de 2008 catalisou uma série de cortes orçamentais draconianos, no setor da saúde.Usando dados desagregados de pesquisa sobre necessidades não atendidas de cuidados de saúdeautorrelatadas, será demonstrado que o aumento das taxas de utilizador e a redução das equipase das instalações de saúde, combinados com a redução do rendimento disponível, estiveramassociados a um aumento drástico das desigualdades no acesso aos cuidados de saúde em Itália.

INDEX

Keywords: access to healthcare; austerity; health inequities; Italy; right to healthPalavras-chave: acesso aos cuidados de saúde; austeridade; injustiças na saúde; direito à saúde;Itália

AUTHOR

ROSSELLA DE FALCO

Human Rights Center “Antonio Papisca”, Università degli Studi di PadovaVia Martiri della Libertà, 2, 35137 Padova, [email protected]


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@cetera


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Sistema Único de Saúde: reduçãodas funções públicas e ampliação aomercado*

Unified Health System: Reduction of Public Functions and Market Expansion

Tânia Regina Krüger

NOTA DO EDITOR

Revisto por Rita Cabral

Introdução

1 O Sistema Único de Saúde (SUS), resultado do movimento da Reforma Sanitária noBrasil, institucionalizou-se como uma política pública estatal, universal,descentralizada, gratuita e com participação da comunidade. Os seus fundamentosexpressam as contradições da sociedade e o caráter liberal, democrático e universalistadesta, ao combinar políticas estatais universais, contributivas e focalizadas em políticasde mercado. Com 30 anos completos em 2018, o SUS encontra-se em franco processo dedilapidação e desconstitucionalização.

2 Esse brutal desmonte do SUS teve início em 2016 e o colocou numa encruzilhada queparece ultrapassar as contrarreformas que vivenciou desde 1990. O desmonte dosprincípios doutrinários (o sentido de público, coletivo, universal, integral eparticipativo) e dos princípios organizativos (base orçamentária, contratação detrabalhadores, resolutividade dos serviços, forma de gestão, etc.) vem acontecendo deforma agressiva, ainda que esses princípios permaneçam na forma da lei (Brasil, 1990a).

3 Assim, nessa conjuntura, o presente texto tem como objetivo problematizar a relaçãoentre público e privado no SUS, considerando a sua tensa trajetória deinstitucionalização e implementação. A desconstitucionalização do SUS, aqui também


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chamada de contrarreforma, está avançando num contexto de desmonte e privatizaçãode empresas e dos serviços públicos estatais. E aí se colocam os desafios para identificare refletir sobre as implicações e imbricações da relação entre público e privado no SUS,pois os interesses privados entranhados no sistema formam uma pressão que estádesmontando o sentido de direito público e coletivo pela necessidade de acesso dessesetor ao fundo público.

4 Tal retrocesso é resultado de um esfacelamento da garantia dos direitos de cidadaniacomo medida do extremo ajuste liberal no campo econômico, fiscal e social da crise,mas que espetacularmente é divulgado como Uma ponte para o futuro (PMDB, 2015),como um manifesto Brasil 200 anos (Mortanari, 2018), como sendo Um ajuste justo (BancoMundial, 2017) e ainda como O caminho da prosperidade – Proposta de plano de governo:constitucional, eficiente e fraterno (Bolsonaro, 2018). Ou seja, é uma conjuntura dedesconstitucionalização que envolve diretamente emendas constitucionais, legislaçãoinfraconstitucional nas esferas nacional e subnacionais, redução do financiamento esucateamento dos serviços públicos. Todo este processo está permeado por uma criseideológica e política que está destruindo, com o apoio dos meios de comunicação, asbases relativamente progressistas do Estado democrático, timidamente construídas.

5 Tendo uma natureza exploratória, o texto foi desenvolvido com base numa revisãobibliográfica e documental e no marco normativo do SUS, bem como na sistematizaçãode experiências oriundas de diferentes vivências políticas e acadêmico-profissionais dotrabalho na saúde. O texto foi estruturado em duas partes: a primeira, sobre a trajetóriade implementação do SUS e suas contrarreformas; a segunda sobre a redução do SUScomo serviço público e a sua ampliação para os serviços privados de saúde. Toda estaanálise crítica não desconsidera que o SUS é uma das políticas sociais mais caras àslutas democrático-populares brasileiras, podendo, portanto, ser considerado umpatrimônio nacional.

1. SUS: conflitos entre os fundamentos democráticose as contrarreformas

6 Segundo os fundamentos do SUS, a saúde não é o resultado de um procedimentobiológico-curativo a ser tratado pelos serviços médicos e medicamentos (Paim, 2011),mas sim resultado de determinações socioeconômicas que devem ter uma resposta noespaço público, mediada pela participação dos sujeitos sociais num contexto de Estadodemocrático.

7 A partir de 1990, o Estado brasileiro foi adequando a sua gestão às políticas neoliberaise se organizando como um Estado liberal-social. O governo de Fernando HenriqueCardoso caracterizou-se pela implementação de políticas estatais e privatistas. Estegoverno questionou as aspirações democráticas da década de 1980 e da Constituição de1988 e colocou-as como empecilho à governabilidade e à modernização; por issoorganizou políticas para a flexibilização do mundo do trabalho e subsidiou asprivatizações com fundos públicos por intermédio do sistema bancário.1

8 Nessa década, o Movimento da Reforma Sanitária, por ter centrado as suas forças naconquista do arcabouço legal, ficou em posição defensiva, por vezes resistindo aosataques ao SUS e por vezes assumindo, através de seus membros, cargos em governosde caráter progressista nas instâncias subnacionais. Evidenciou-se na época a


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fragilidade político-organizacional dos espaços institucionalizados de participação –Conselho e Conferências –,2 apesar de resistências locais para enfrentar odesfinanciamento, a desconcentração de serviços e a recentralização das decisões e dosrecursos. A reafirmação do SUS como política pública universal de caráter coletivo eobrigação do Estado, na maioria das vezes nos espaços dos Conselhos e Conferências,assim como nos movimentos sociais, na academia e na organização dos gestores, cedeulugar a reivindicações mais imediatistas para que se cumprisse a lei, organizasse a redede serviços, se realizassem concursos públicos e se prestassem os serviços (Bravo eMenezes, 2010).

9 Em 2002, a vitória de Lula, do Partido dos Trabalhadores (PT), nas eleiçõespresidenciais, teve um significado real e simbólico para um país dotado de enormeconservadorismo e desigualdades. Foi uma vitória tardia, pois para poder vencer egovernar, o PT fez concessões, abandonou bandeiras que o caracterizaram desde 1979 ealiou-se a grupos políticos de centro-direita vinculados ao capital industrial, buscandoos riscos do apoio de uma base pluriclassista, mas sempre disposto à mediação entre asações que buscavam a elevação dos padrões de vida dos mais pobres e as quepropiciaram ganhos à elite (Antunes, 2004; Belluzzo, 2013).

10 Na saúde, como nas demais políticas sociais, os governos do Partido dos Trabalhadorespropiciaram certa reanimação das forças progressistas, destacando-se o retorno àconcepção de Reforma Sanitária; a escolha de profissionais comprometidos com aReforma Sanitária para ocuparem cargos de responsabilidade no Ministério da Saúde; aconvocação das Conferências Nacionais de Saúde com regularidade; a aprovação daPolítica de Atenção Básica e do Pacto Pela Saúde em 2006 para retomar algunsprincípios do SUS; a ênfase na Estratégia de Saúde da Família como políticaestruturante e porta de entrada preferencial no SUS; o incentivo à formação deprofissionais de saúde com perfil para trabalhar no SUS; a aprovação da PolíticaNacional de Medicamentos e da Saúde Bucal entre outros (Bravo e Menezes, 2010).

11 Ao mesmo tempo evidenciaram-se fragilidades na implementação do SUS, como porexemplo uma concepção de Seguridade Social desarticulada da Previdência eAssistência Social; a não aprovação do Plano Único de Cargos, Carreira e Salários(PCCS); o silêncio do Ministério da Saúde perante a multiplicação de serviços entreguesàs organizações sociais, nas esferas subnacionais do SUS, e perante as inúmerasdenúncias quanto à qualidade desses serviços; e, também, a omissão do Ministérioperante a desvinculação formal dos hospitais das universidades, quando em 2011 foicriada a Empresa Brasileira de Serviço Hospitalares – EBSERH, uma empresa pública dedireito privado destinada a gerir os 37 hospitais Universitários públicos-federais (Brasil,2011a).

12 Com a assunção ilegítima a Presidência da República, por Michel Temer em 2016, oEstado brasileiro vem adotando políticas radicais de austeridade fiscal, num processocontínuo de redução dos direitos sociais e de mercantilização da gestão e prestação dosserviços sociais, bem como de redução do financiamento da seguridade social. Com asua agenda conservadora, o governo Temer não só acirrou o fortalecimento do setorprivado em detrimento do SUS, como oportunizou as maiores manifestações dopopulismo de direita. Nesse governo, a aplicação da política de austeridade adquiriucontornos dramáticos, deixando o SUS com uma “atuação subordinada e subalterna,como recurso complementar ao mercado” (Miranda, 2017: 399).


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13 Destacamos aqui algumas medidas recentes que expressam este desmonte do SUS:a aprovação da Emenda Constitucional (EC 95), que limita o crescimento das despesasprimárias à taxa de inflação, durante um período de 20 anos;

a revisão das diretrizes da Atenção Básica (Brasil, 2017b), num sentido oposto à perspectivaintegradora da Atenção Primária à Saúde (APS);

a significativa redução do Programa Farmácia Popular;

a alteração das diretrizes da Política Nacional de Saúde Mental (PNSM), o que significa umretrocesso da Reforma Psiquiátrica Brasileira e que pode ter como consequência adesassistência e retorna da institucionalização;

a limitação do credenciamento das Instituições de Educação Superior exclusivamente àoferta de cursos de graduação na modalidade à distância, sem prever um tratamentodiferenciado para a área da saúde (Brasil, 2017a);

a decisão da Agência Nacional de Vigilância Sanitária (Anvisa) relativamente a liberar o usode Benzoato de Emamectina, um agrotóxico agressivo, que havia sido proibido em 2010 porelevada neurotoxicidade e suspeita de causar malformações;

a redução dos blocos ou áreas de financiamento do SUS de seis3 para dois: um de custeio, queconcentra a quase totalidade dos recursos federais, e outro de investimento. Em nome daflexibilização, esta política fragmenta e desfigura o sistema de financiamento definido peloPacto pela Saúde (Brasil, 2007), comprometendo nas esferas infranacionais a manutenção e aampliação dos serviços e dando mais liberdade à gestão para atender as conveniênciaspolíticas locais (Brasil, 2017c).

14 Em fins de 2018 a eleição de Jair Bolsonaro para presidente representou no país umaescancarada viragem à direita e uma divisão profunda da sociedade. Vive-se uma ondareacionária diferente das outras, que tenta acabar com a distinção entre ditadura edemocracia. A opinião pública está sendo destruída com notícias falsas quetransformam o adversário em inimigo (B. S. Santos, 2018). Para se eleger, o novopresidente apresentou-se como candidato antissistema, encarnou a rejeição e asinsatisfações populares com um discurso violento, baseado no senso comum. As suasdeclarações antidemocráticas receberam da população apoio acrítico incondicional.Este governo, segundo Martins (2018), inicia-se com uma aliança entre a burguesiaemergente, centrada no empresariado neopentecostal, o agronegócio, o rentismo, aoficialidade militar, o grande capital estrangeiro e o imperialismo estadunidenseantiliberal.

15 Mesmo antes de iniciar o governo, o SUS teve uma das suas maiores perdas, pois oGoverno cubano decidiu retirar do país os profissionais que pertenciam ao ProgramaMais Médicos,4 em função das “declarações ameaçadoras e depreciativas” do presidenteeleito para com aquele governo. A saída de aproximadamente 8500 médicos do paísafetou 28 milhões de pessoas em 1575 municípios brasileiros (Matoso, 2018; ConselhoNacional de Saúde, 2018).

16 O ministro da saúde do novo governo, Luiz Henrique Mandetta, em seu discurso deposse, referenciou o SUS como uma continuidade de saberes, ao mesmo tempo queprometeu cumprir o desafio constitucional de a saúde ser um direito de todos e umdever do Estado. Mas essa promessa não combina com a ênfase que ele colocou nogrande compromisso com a família, com a fé, com o país e com a pátria, revelando a suahistórica relação com o setor filantrópico e com empresas e políticos vinculados aosetor privado da saúde (Brasil, 2019b).

a.

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17 Ao longo dos seus 30 anos, o SUS foi marcado por momentos de valorização e pormomentos de desvalorização dos seus fundamentos, ou seja, o Estado democrático, aigualdade, a democracia e a saúde como direito coletivo e obrigação do Estado. Nosentido da valorização, o SUS ganhou sustentabilidade institucional, por meio de umarede de instituições de ensino e pesquisa nas universidades, nos institutos e nas escolasde saúde pública, nos colegiados de participação e controle social e por meio de umarede de entidades e movimentos sociais que o defendem. Igualmente ganhoumaterialidade que se expressa em estabelecimentos, trabalhadores, equipamentos,tecnologias, sistemas de informação, serviços amplamente reconhecidos, indicadoresde atendimento e recursos efetivamente gastos que se contam em milhões5 (Paim,2018). O impacto dos serviços do SUS nas condições de vida parece ser muito positivo, oqual se deve a diversas medidas e políticas, de entre as quais se destacam: o combate àpobreza, o programa farmácia popular, o serviço de urgência (Serviço de AtendimentoMóvel de Urgência – SAMU), o programa de saúde bucal, a inclusão social (políticas desaúde para as populações indígenas, quilombolas, ribeirinhas, em situação de rua eLGBT), o Programa Mais Médicos, a criação e ampliação de unidades e equipes daEstratégia Saúde da Família e as Unidades de Pronto Atendimento (UPA) (Brasil, 2011b,2016).

18 No sentido inverso, estas três décadas foram também marcadas por ações políticasregressivas, sendo imperioso reconhecer a existência de obrigações legais que nãoforam cumpridas, designadamente as relacionadas com o princípio da universalidade eo financiamento público.

19 Apesar de todos os governos terem assumido a defesa do SUS nas campanhas eleitorais,nenhum deles adotou seriamente a sua implantação como projeto prioritário devido àpressão da agenda neoliberal. Segundo Paim:

esse aspecto negativo é agravado pelas limitadas bases sociais e políticas do SUS quenão conta com a força de partidos, nem com o apoio de trabalhadores organizadosem sindicatos e centrais para a defesa do direito à saúde inerente à condição decidadania […]. O SUS sofre resistências de profissionais de saúde, cujos interessesnão foram contemplados pelas políticas de gestão do trabalho e educação em saúde.Além da crítica sistemática e oposição da mídia, o SUS enfrenta grandes interesseseconômicos e financeiros ligados a operadoras de planos de saúde, a empresas depublicidade e a indústrias farmacêuticas e de equipamentos médico-hospitalares.(2018: 1725)

20 A permanente indefinição quanto ao seu financiamento conduziu o SUS a uma enormeinstabilidade e a uma situação de subfinanciamento crônico. A insuficiência dosrecursos do SUS reflete-se negativamente na rede de infraestruturas públicas, naremuneração dos seus trabalhadores e nas respostas à população, obrigando-o acomprar serviços ao setor privado. Para Paim (ibidem), essa indefinição leva a um duploboicote ao SUS: “um boicote passivo através do subfinanciamento público e ganha forçaum boicote ativo”, quando o Estado reconhece e privilegia o setor privado comsubsídios, empréstimos, desonerações e contratualizações. Este favorecimento do SUSao setor privado torna o sistema de saúde brasileiro, segundo Ocké-Reis (2018: 2037),numa estrutura duplicada e paralela, forjando uma falsa equidade do sistema.Parecendo aceitável que o Estado atenue o conflito distributivo, decorrente daaplicação de subsídios aos estratos superiores de renda, ele acaba por promover omercado de planos de saúde privados.


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21 Também o modelo tecnoassistencial e gerencial6 não sofreu descontinuidade. Persiste aperspectiva de uma administração pública gerencial que se pauta pela proposta deesvaziamento do papel do Estado de regulador das relações e de prestador de serviçospúblicos, ficando as suas atividades vinculadas às demandas do mercado. Para MarcoAurélio Nogueira, este clima ideológico solidificou-se quando as forças neoliberaisvieram “a público proclamar que o Estado simbolizava o atraso indesejável e aconstituição da modernidade, por todos almejada, dependia da negação do Estado”(Nogueira, 1998: 124). Deste modo, o entendimento sobre administração públicagerencial dominante, que coloca o Estado como gestor ineficiente e apresenta a gestãogerencial como sinônimo de eficiência, está de acordo com o segmento político eeconômico que o defende e com o seu projeto político-econômico. Segundo Souza Filho(2006: 323), a hegemonia ideológica do projeto gerencialista ataca a finalidade deuniversalização de direitos, a dimensão racional e impessoal da ordem administrativaburocrática e promove a privatização de empresas e dos serviços públicos estatais.

22 São inúmeras as situações que vêm descaracterizando e desconstitucionalizando o SUSque já não cabem nos limites desse texto. Mas é certo que no SUS, como em grandeparte do território nacional, há um imenso descuido com a ambiência, com a eficiênciada gestão pública e, o mais grave, com as pessoas que usam e trabalham no sistema,criando inúmeras barreiras à base de sustentação social e ao reconhecimento nacionaldo SUS. O SUS vem se transformando, gradualmente, em mais um espaço dominadopela velha e tradicional promiscuidade da política brasileira, confirmando um padrãode descaso e de desrespeito em relação à dignidade humana e ao uso da riquezasocialmente produzida.7

2. SUS: funcional ao setor privado e reduzido nas suasfunções públicas e coletivas

23 Os 30 anos do SUS também foram marcados por uma queda do seu peso na despesapública, entre 2010 e 2015, enquanto a saúde privada passou a representar uma fatiamaior do que em países ricos.8

24 A história do SUS pautou-se por uma contradição fundamental que consiste nasegmentação dos serviços devido ao uso da dupla cobertura pelo sistema público e pelosetor privado. A defesa dos fundamentos da Reforma Sanitária e do SUS sempre foramtensionados pela corrente antissanitarista, que defende o Estado mínimo, o paradigmaprivatista, os serviços curativos e o médico-centrado. Este setor sobrevive e moderniza-se com o financiamento do Estado e com a venda de seus serviços e produtos ao SUS,embora vinculado aos planos e seguros privados, à rede de hospitais filantrópicos e aosetor privado da saúde (hospitais, clínicas, indústria de medicamentos e equipamentos)(Bahia, 2018).

25 O setor privado da saúde defende que o sistema público é para atender os pobres, asregiões distantes do país, os serviços de vigilância à saúde, atender as calamidades egarantir os serviços de alto custo, pois nesses serviços o próprio setor privado éusuário. Este segmento, segundo Ronaldo dos Santos (2018a), estrutura-se a partir deuma racionalidade privada mercantil e vem operando uma inversão de valores,convertendo a universalidade e a gratuidade dos serviços em resíduos históricos


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regressivos e em privilégios, e defende as parcerias privadas como arranjos superiores àadministração direta estatal.

26 Estima-se que 30% da população brasileira seja cliente de planos privados de saúde(Bocchini, 2018). Esta segmentação evidencia o aumento das desigualdades em saúde, odeslocamento da base social de apoio ao SUS e promove a cultura corporativa dedireitos presente nas relações de trabalho. Conforme Ronaldo dos Santos (2018a), osplanos coletivos privados representam 76% desse mercado e se relacionamessencialmente com as demandas sindicais.9 Essa cultura corporativa de direitos nasrelações de trabalho é uma das causas do aumento das desigualdades em saúde, da nãouniversalização dos serviços e impõe sérios limites à construção de uma base social deapoio ao SUS. Para Ronaldo dos Santos (2018a), este tipo de prática do mundo dotrabalho ainda alimenta a racionalidade econômico-corporativa, o desconhecimento damagnitude dos serviços que o SUS realiza na atenção aos acidentes de trabalho e a baixaintegração dos Centros de Referência em Saúde do Trabalhador (CEREST) – nos serviçosde atenção básica, média e alta complexidade.10

27 A arrecadação do governo federal é reduzida, pois a pessoa física ou jurídica podeabater do imposto a pagar os gastos comprovados com planos e serviços particulares desaúde. Outra contradição no plano institucional do SUS é que os funcionários dospoderes executivo, legislativo e judiciário – isto é, o núcleo do poder decisório doEstado brasileiro – são cobertos por planos privados de saúde parcialmente financiadospelos empregadores públicos, e contam com benefícios da renúncia fiscal. Tal benefíciosignifica a isenção do pagamento de tributos, especialmente no Imposto de Renda, porparte da pessoa física ou jurídica que contrata o plano privado de saúde. Essa política derenúncia da arrecadação fiscal provoca uma subtração de recursos ao SUS quecorrespondeu a um terço das despesas com Ações e Serviços Públicos de Saúde doMinistério da Saúde, entre 2003 e 2015 (Ocké-Reis, 2018). A isenção fiscal concedida aosplanos de saúde por parte da União possibilita parte dos altos investimentos privadosda saúde. “Esses subsídios equivaleram a 30% dos gastos federais com saúde em 2016”(Sobrinho, 2018).

28 Tais iniciativas espelham a tendência de fortalecimento do setor privado em saúde,mas, contraditoriamente, o mercado requer um SUS que lhe seja funcional, nos termosde Paim:

este SUS que está aí ainda é muito orgânico aos interesses privados. Além decomprar medicamentos e equipamentos, atender às empreiteiras para construirUPAs e hospitais, o SUS funciona como um resseguro para essas empresas de planosde saúde. Quando o risco sobe, elas jogam o cliente para o público. Então, aprincípio, não é interessante para eles que o SUS acabe. (apud Mathias, 2018)

29 Para além do problema histórico do subfinanciamento, novas estratégias do capitalpara a saúde corroem os pilares de um sistema público e universal, pressupondo aresponsabilidade dos indivíduos e a ajuda do Estado, desaparecendo a figura jurídica dodireito à saúde. Para exemplificar, a tramitação no Brasil da criação dos Planos deSaúde Acessíveis (populares) se assenta nas seguintes premissas: segmentação dascoberturas assistenciais, redução da lista dos procedimentos com cobertura obrigatória,redução do valor que as operadoras devem restituir ao SUS e reajustes regulares damensalidade de pessoas com mais de 60 anos de idade, regulados pela Lei n.º 9.656 de1998 (ABRASCO, CEBES e IDEC, 2017; Brasil, 1998).


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30 O processo de desconstitucionalização do SUS pode ainda ser ilustrado com inúmerasalterações legislativas, tais como a Lei n.º 13.097/2015, que estabelece a permissão doinvestimento de capital estrangeiro nos serviços de saúde e da contratualização comoserviço complementar ou como gestor do SUS (Brasil, 2015a). Na análise de Mendes eFuncia (2016: 159) “essa Lei veio para dificultar ainda mais a possibilidade deampliarmos o direito à saúde e assegurar a insaciabilidade do capital na forma deapropriação do fundo público”.

31 As contradições fundamentais e os dados oficiais sobre SUS permitem-nos afirmar comcerta facilidade que o SUS nunca foi universal. As proporções relativas da despesapública (42%) e privada (58%), que pouco oscilaram nas últimas três décadas (Bahia,2018), ajudam a sustentar a evidência da não universalização. Mas a estes gastosprivados estão vinculados cerca de 50 milhões de pessoas, ou seja, a 25% da populaçãobrasileira, que também utiliza o SUS. “O setor público predomina na produção total deatividades (65%), mas recebeu apenas 10% dos valores de remuneração, ao passo que oprivado e o filantrópico, responsáveis por 35% dos atendimentos, 90%” (ibidem). Nãoexistindo solução única, muito menos de corte tecnocrático, para universalização doSUS, um dos caminhos é aumentar a despesa pública em saúde.

32 A despesa total em saúde, no Brasil, atingiu 8,3% do Produto Interno Bruto (PIB) em2014, valor próximo ao de alguns países desenvolvidos (Figueiredo et al., 2018).Contudo, em relação à despesa total em saúde, a despesa pública foi de apenas 48,2%,inferior ao de países latino-americanos (Argentina, 67,1%; Colômbia, 76%; Costa Rica,75%; Cuba, 93%; e México, 51,7%) e equiparável ao dos Estados Unidos (47,1%). Os paísescom forte investimento público despendem mais de 70% da despesa total em saúde(Jornal Económico, 2017; Reis et al., 2016). Evidências internacionais sugerem que auniversalização dos sistemas de saúde implica gastos públicos iguais ou superiores a70% dos gastos totais em saúde, situando-se o Brasil mais de 20 pontos percentuaisabaixo desse patamar.

33 Esta funcionalidade do SUS no setor privado é evidenciada em manifestações do setorprivado da saúde, como por exemplo o Fórum Saúde do Brasil, realizado em 2018,promovido pela Folha de São Paulo e patrocinado pela Amil e ANAB (AssociaçãoNacional de Administradoras de Benefícios). Na avaliação dos especialistas queparticiparam desse Fórum, o SUS, que faz 30 anos, é referência em saúde pública, porémtem o desafio de melhorar o atendimento no tratamento de média complexidade,justamente no serviço que é mais lucrativo para o setor privado (Lott, 2018).

34 Na avaliação de Paim (2018), “a luta pela privatização está saindo do armário echegando ao DNA do nosso arcabouço legal que é a Constituição de 1988. É um ataqueao pacto que foi construído depois da ditadura”. Neste contexto e a partir de 2016apareceram no cenário nacional várias entidades a propor uma segunda alma para oSUS, ou a sua refundação numa base de complementaridade entre público e privado. É ocaso da Associação Nacional dos Hospitais Privados (Anahp), a Coalizão Saúde, aFederação Brasileira de Planos de Saúde (FEBRAPLAN) e o Colégio Brasileiro deExecutivos da Saúde (CBEXs), que convergem na defesa da integração total entre o SUSe o setor privado (Mathias, 2016).

35 Por esta via, a esfera pública está sendo colocada a serviço do mercado e alijada da suaestrutura institucional e dos seus fundamentos11 como serviço público de cidadania.Assim, a defesa do direito à saúde e do SUS torna-se uma agenda permanente para osmovimentos sociais e entidades que historicamente lutaram para a construção e a


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defesa do SUS constitucional, como o Centro Brasileiro de Estudos de Saúde (CEBES), aAssociação Brasileira de Saúde Coletiva (ABRASCO), o Instituto de Direito Sanitário(IDISA) e a Frente Nacional Contra a Privatização da Saúde, entre outros segmentossociais progressistas.

36 A estratificação complexa do SUS e a relação complementar com o setor privadomarcaram os serviços que foram ou se aproximaram da universalidade: vigilânciasanitária e epidemiológica, vacinações, zoonoses, vigilância da água, atenção básica,medicamentos para tuberculose, hanseníase, HIV/AIDS, hipertensão, diabetes, serviçosde alto custo e alta complexidade como a nefrologia e transplantes. O impacto dessaspolíticas de saúde foi reconhecido nacional e internacionalmente. A revista BritishMedical Journal, por exemplo, destacou os progressos associados aos vários programassociais e de saúde que levaram a “um dos declínios mais rápidos na mortalidade abaixode 5 anos já registado” (Hennigan, 2010: 1190).

Considerações finais

37 Nos 30 anos do SUS prevaleceu uma acepção positiva sobre a natureza democrática doprojeto, mas a democratização dos cuidados de saúde permaneceu pendente derealização. Nessa implementação, o bloco político institucional e organizativo queformulou o SUS perdeu a sua capacidade de resistência e defesa dos princípios dosistema público de saúde. Assim, as agendas políticas dos governos dessas três décadasforam conformando novas tendências em relação à direção ideo-política do SUS. Aperspectiva privatista alargou a relação com setor privado renovando as formas decontratos, subsídios e empréstimos suportados pelo fundo público. As associações e osgrupos de representantes do setor privado, que raramente se manifestavampublicamente, estão aumentando a sua presença e o debate na agenda pública do SUS,em nome de uma retórica de defesa da saúde, que indiferencia o setor público e oprivado. A defesa do SUS constitucional reside no segmento que defende as bandeirasdo Movimento da Reforma Sanitária, mas que é hoje claramente contra-hegemônico.

38 Sabemos das contradições e divergências que acercam o debate da defesa do SUS noconjunto de entidades e movimentos sociais, mas torna-se necessária a articulação emtorno da construção de uma política unitária e da revitalização das bandeiras de lutasem defesa dos direitos sociais, trabalhistas e previdenciários, de modo a alterar apresente correlação de forças que pende para o mais sombrio da humanidade.

39 O projeto brasileiro da Reforma Sanitária necessita dos rituais democráticos para seguiro processo de implementação do SUS de acordo com seus fundamentos. Os opositoresde um sistema público de saúde sobreviveram à redemocratização, ao Movimento daReforma Sanitária e ampliaram a sua ação nos 30 anos do SUS. Assim, a bandeira degestão pública estatal, dos serviços públicos e do investimento no setor público nãopodem ser reivindicação menor do segmento que defende o SUS.


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Santos, Boaventura de Sousa (2018), “Vivemos um ciclo reacionário diferente, que tenta acabarcom a distinção entre ditadura e democracia”, El País, 6 de novembro. Entrevistado por JavierMartín Del Barrio a 2 de novembro. Consultado a 19.12.2018, em https://brasil.elpais.com/brasil/2018/11/02/internacional/1541181915_050896.html.

Santos, Chico (1997), “BNDES financia 23,6% das privatizações”, Folha de São Paulo, 18 dedezembro. Consultado a 10.02.2019, em https://www1.folha.uol.com.br/fsp/brasil/fc181216.htm.

Santos, Ronaldo Teodoro dos (2018a), “SUS: um novo capítulo de lutas”, Ciência & Saúde Coletiva,23(6), 1719-1720. Consultado a 16.08.2018, em http://dx.doi.org/10.1590/1413-81232018236.05672018.


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http://outraspalavras.net/outrasaude/2018/03/22/jairnilson-paim-uma-leitura-sobre-os-30-anos-do-sus/

http://outraspalavras.net/outrasaude/2018/03/22/jairnilson-paim-uma-leitura-sobre-os-30-anos-do-sus/

https://g1.globo.com/politica/noticia/2018/11/15/saida-de-cuba-do-mais-medicos-afeta-28-milhoes-de-pessoas-diz-confederacao-dos-municipios.ghtml



http://bvsms.saude.gov.br/bvs/publicacoes/sistema_saude_brasil_organizacao_financiamento.pdf

http://bvsms.saude.gov.br/bvs/publicacoes/sistema_saude_brasil_organizacao_financiamento.pdf

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-11042017000200385&lng=pt&nrm=iso

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-11042017000200385&lng=pt&nrm=iso

https://www.infomoney.com.br/politica/flavio-rocha-explica-movimento-brasil-200-e-pede-presidente-liberal-na-economia-e-conservador-nos-costumes/

https://www.infomoney.com.br/politica/flavio-rocha-explica-movimento-brasil-200-e-pede-presidente-liberal-na-economia-e-conservador-nos-costumes/

http://www.scielo.br/pdf/csc/v23n6/1413-8123-csc-23-06-2035.pdf

http://www.scielo.br/pdf/csc/v23n6/1413-8123-csc-23-06-2035.pdf

http://dx.doi.org/10.1590/1413-81232018236.09172018

http://dx.doi.org/10.1590/1413-81232018236.09172018

https://www.fundacaoulysses.org.br/wp-content/uploads/2016/11/UMA-PONTE-PARA-O-FUTURO.pdf

https://www.fundacaoulysses.org.br/wp-content/uploads/2016/11/UMA-PONTE-PARA-O-FUTURO.pdf

https://brasil.elpais.com/brasil/2018/11/02/internacional/1541181915_050896.html

https://brasil.elpais.com/brasil/2018/11/02/internacional/1541181915_050896.html

https://www1.folha.uol.com.br/fsp/brasil/fc181216.htm

https://www1.folha.uol.com.br/fsp/brasil/fc181216.htm

http://dx.doi.org/10.1590/1413-81232018236.05672018

http://dx.doi.org/10.1590/1413-81232018236.05672018

Santos, Ronaldo Teodoro dos (2018b), “A Teoria Sanitária e o Momento Corporativo: a crítica deum desafio não superado”, in Sonia Fleury (org.), Teoria da Reforma Sanitária: diálogos críticos. Riode Janeiro. Fiocurz, 183-220.

Sobrinho, Wanderley Preite (2018), “Peso do SUS cai, e saúde privada tem fatia maior do que empaíses ricos”, UOL, 17 de dezembro. Consultado a 19.12.2018, em https://noticias.uol.com.br/saude/ultimas-noticias/redacao/2018/12/17/sus-30-anos-gasto-publico-cai-ao-menor-nivel-em-relacao-ao-setor-privado.htm.

Souza Filho, Rodrigo de (2006), “Estado, burocracia e patrimonialismo no desenvolvimento daadministração pública brasileira”. Tese de Doutorado em Serviço Social apresentada naUniversidade Federal do Rio de Janeiro – Faculdade de Serviço Social, Rio de Janeiro, Brasil.

NOTAS*. Este texto é parte dos resultados do projeto da pesquisa “Saúde e Serviço Social: planejamento,gestão, participação e exercício profissional”, desenvolvido no período entre 2015 e 2019,vinculado ao Núcleo de Estudos em Serviço Social e Organização Popular (NESSOP) doDepartamento de Serviço Social da Universidade Federal de Santa Catarina (UFSC), no Brasil, ecoordenado pela autora pesquisadora PQ2 do CNPq. O texto integra também o relatório depesquisa de pós-doutorado da autora no Centro de Estudos Sociais da Universidade de Coimbra,Portugal, com orientação do Professor Doutor Mauro Serapioni, realizado em 2018.1. O Banco Nacional de Desenvolvimento Econômico e Social (BNDES), 100% estatal, vem sendo oprincipal gestor das privatizações federais e assessor das privatizações estaduais brasileiras.Como o mercado de capitais não tem financiado as privatizações o BNDES, faz empréstimosdiretos aos compradores (C. Santos, 1997).2. A Constituição de 1988, artigo 198, indica que uma das diretrizes do SUS é a participação daComunidade. A Lei 8.142/1990 regulamentou determinou que a participação da comunidade sedará desse em dois espaços colegiados, o Conselho e as Conferências (Brasil, 1990a, 1990b). 3. Os blocos de financiamento do Pacto pela Saúde eram: Atenção Básica, Atenção de Média e AltaComplexidade Ambulatorial e Hospitalar, Vigilância em Saúde, Assistência Farmacêutica, Gestãodo SUS e Investimentos na Rede de Serviços de Saúde (Brasil, 2007).4. O Programa Mais Médicos (PMM) foi criado em 2013 pelo Governo Federal para a melhoria doSUS, levando mais médicos para regiões onde há escassez ou ausência desses profissionais. Oprograma previu mais investimentos para construção, reforma e ampliação de Unidades Básicasde Saúde (UBS), além de novas vagas de graduação e residência médica para qualificar a formaçãodos seus profissionais (Brasil, 2019a).5. A informação sobre os números e as realizações do SUS pode ser colhida nos Planos Nacionaisde Saúde quadrienais (2004-2007; 2008-2011; 2012-2015; 2016-2019).6. O projeto gerencialista no âmbito de um projeto político-econômico conservador avança demaneira considerável no desmonte e privatização de empresas e dos serviços públicos estatais,pois reivindica para si o atendimento dos que têm acesso ao mercado e o acesso ao fundo públicopara fazer a gestão dos serviços SUS. Com essa política, os usuários dos serviços passamprogressivamente a ser vistos como consumidores e clientes ao invés de cidadãos, ficando oEstado a atender os comprovadamente mais pobres (Souza Filho, 2006). Sob o pretexto de maioreficiência, exemplificamos, o Estado brasileiro repassa recursos aos empresários através deinúmeras figuras jurídicas, como as organizações sociais (OS), as Parcerias Público-Privadas(PPP), as Fundações Estatais de Direito Privado e Empresas Públicas (como a Empresa Brasileirade Serviços Hospitalares – EBSERH).


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https://noticias.uol.com.br/saude/ultimas-noticias/redacao/2018/12/17/sus-30-anos-gasto-publico-cai-ao-menor-nivel-em-relacao-ao-setor-privado.htm



7. Mais um exemplo do descaso com proteção social da população brasileira pode serexemplificado no Decreto presidencial n.º 9.699, de 8 de fevereiro de 2019. Transfere dotaçõesorçamentárias constantes dos Orçamentos Fiscal e da Seguridade Social da União para diversosórgãos do Poder Executivo Federal, para encargos financeiros da União e para transferências aEstados, Distrito Federal e Municípios, no valor de R$ 606 056 926 691,00.8. Os dados da pesquisa Conta-Satélite de Saúde Brasil 2010-2015, do Instituto Brasileiro deGeografia e Estatística (IBGE), evidenciam que os gastos privados somaram 57,6% do total dosgastos com saúde no país e os gastos do setor público representaram 42,4% do total em 2015(Sobrinho, 2018).9. A relação entre os sanitaristas e os sindicalistas na análise de Santos (2018b) caracteriza-sepela persistência do “não diálogo”. Com a implementação do SUS, a assistência à saúde para parteda classe trabalhadora sindicalizada transitou gradativamente do modelo corporativo públicoestatal para uma dimensão corporativa mercantil. Os estudos do autor apontam que as demandaspor planos de saúde privados tem sido uma pauta privilegiada nos acordos e convenções coletivasde trabalho e, contraditoriamente, o tema não ganhou centralidade nos debates dos sanitaristasdefensores do SUS.10. O CEREST é um local de atendimento SUS especializado em Saúde do Trabalhador, o qualrecebe usuários encaminhados pela a rede básica; o trabalhador formal dos setores privado epúblico; o trabalhador autônomo; o trabalhador informal; e o trabalhador desempregadoacometido de doença relacionada com o trabalho realizado. O CEREST presta assistênciaespecializada aos trabalhadores acometidos por doenças e/ou acidentes relacionados com otrabalho; realiza promoção, proteção, recuperação da saúde; investiga as condições do ambientede trabalho utilizando dados epidemiológicos e é uma fonte geradora de conhecimento paraindicar se as doenças estão relacionadas com as atividades que elas exercem (Brasil, 2015b).11. Entendemos por fundamentos do SUS: a saúde como direito universal, o conceito ampliado desaúde, os seus objetivos, competências e princípios (artigos 5.º ao 7.º da lei n.º 8.080/1990), adeterminação social da saúde e a gestão pública estatal com base no direito público.

RESUMOSEste texto tem como objetivo problematizar as tensões na relação entre público e privado doSistema Único de Saúde (SUS) brasileiro. As comemorações dos 30 anos do SUS aconteceramnuma conjuntura política na qual o país se confronta com um retrocesso político-institucionalsem precedentes e com um esfacelamento da garantia dos direitos de cidadania. Assumindo umanatureza exploratória, o texto foi desenvolvido com base numa revisão bibliográfica edocumental e no marco normativo do SUS. Este estudo trata brevemente das contrarreformasque foram golpeando o SUS, desde a sua regulamentação e apresenta indicadores de como estevem se tornando funcional para o setor privado da saúde. Toda esta análise crítica nãodesconsidera que o SUS construiu serviços públicos relevantes e é uma das políticas sociais maiscaras às lutas democrático-populares, podendo ser considerado, portanto, um patrimônionacional.

This text aims to discuss the tensions in the relationship between the public and the privatesectors in the Brazilian Unified Health System (UHS). The celebrations of the 30th anniversary ofthe UHS took place in a political conjuncture in which the country was facing an unprecedented


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setback in the political and institutional process and a disintegration of the guarantee ofcitizenship rights. Assuming an exploratory nature, the study was based on a bibliographical anddocumentary review of UHS regulations. It deals with counter-reforms that have been strikingthe UHS since its inception and displays indicators of how it has become functional to the privatehealth sector. All this critical analysis does not disregard the fact that the UHS has built relevantpublic services and that it is one of the most important achievements in social policies fordemocratic and popular struggles, and can therefore be considered a national heritage.

ÍNDICE

Palavras-chave: Brasil, política social, relação entre público e privado, Sistema Único de SaúdeKeywords: Brazil, relationship between public and private, social policy, Unified Health System

AUTOR

TÂNIA REGINA KRÜGER

Universidade Federal de Santa CatarinaRua Eng.º Agronômico Andrei Cristian Ferreira, s/n, Trindade, 88040-900 Florianópolis, SantaCatarina, [email protected]


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Debate sobre os fundamentos doconservadorismoDebate on the Foundations of Conservatism

Rosana Mirales

Introdução

1 Em estudos mais recentes, propusemo-nos compreender o conservadorismo e as formaspor que esse pensamento social e essa ideologia influenciam o Serviço Social, por sernossa área de atuação e pesquisa (Mirales, no prelo). Sintetizando muito, oconservadorismo influencia o Serviço Social, desde logo, através da reconfiguração daspolíticas de ensino superior, o que, na situação brasileira, aos poucos modifica a ofertados cursos presenciais para a modalidade a distância e, nesse processo, pode-seidentificar a clara preocupação com a diplomação, que não assegura a formaçãoqualificada que a complexidade do trabalho com as políticas sociais exigem. Esseprocesso força também a reorientação dos conteúdos da formação profissional em favordo processo imposto pelo Estado neoliberal, que adota, sem questionar, asdeterminações das agências financiadoras externas, as normas para o pagamento dadívida externa e os ajustes fiscais necessários para o andamento da economia do país(Lima, 2002). Embora as entidades que representam os assistentes sociais sintam oimpacto do atual contexto regressivo, pode-se dizer que isto ocorre sem as atingirdiretamente em sua direção social, por evidenciar o desenvolvimento e as posturasdessas entidades, a contraposição ético-política ao conservadorismo. Contudo, oconservadorismo corrói a sua orientação ético-política, na medida em que contribuipara a formação de assistentes sociais no quadro de outra concepção teórico-filosóficaque se distancia de uma perspectiva teórico-crítica, e isso com fortes repercussões nasdimensões técnico-operativas da profissão.

2 Neste texto, toma-se, como questão de fundo, a regressividade cultural vivenciada noatual contexto histórico, procurando reavaliar e atualizar os debates sobre oconservadorismo e o seu impacto nas instituições democráticas. Foram incorporadas


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categorias analíticas que compreendem o conservadorismo como parte do processo deuma “tendência geral da decadência ideológica” (Lukács, 1981: 112) da burguesia que,na segunda metade do século XX, se configurou como a “miséria da razão” (Coutinho,2010: 44), se revelou complacente com a continuidade do projeto societário baseadonum modo de produção que gera desigualdades insuportáveis e recorre ao moralismocomo forma de coação sobre a liberdade. Não há condições de esclarecer os argumentosde tais autores em torno do debate, entretanto, tal perspectiva indica um caminhoprofícuo de análise sobre o pensamento conservador como uma expressão culturalprópria da sociabilidade capitalista.

3 Nos levantamentos e nas seleções bibliográficas realizados acerca daqueles debates,identificamos muitos autores em várias áreas do conhecimento que se dedicaram aoestudo do conservadorismo. De entre eles, destacamos o cientista político Josep Baquésque tem contribuído, mais recentemente, para uma síntese das trajetórias dopensamento conservador e, em particular, para a compreensão da atual configuraçãoda associação do pensamento conservador com o pensamento liberal. O primeiro textoidentificado do autor foi El neoconservadurismo: fundamentos teóricos y propuestas políticas,publicado em 2000, que, pode-se dizer, teve a continuidade naquele lançado em 2017,intitulado El liberalismo-conservador. Fundamentos teóricos y recetario político ss. XVIII-XX,do qual se apresenta aqui uma análise, com vista a contribuir para o debate necessáriosobre o tema.

4 Os referenciais teórico-metodológicos adotados por Baqués aproximam-se da teoriasocial de Max Weber. Baqués busca, por meio da análise de autores previamenteselecionados pelas suas posturas conservadoras, a construção de variáveis e de tiposideais. O que se pretende, neste texto, é expor a obra de Baqués (2017), dada a suarelevância para os estudos sobre o conservadorismo e, posteriormente, apresentaralguns contributos para a análise teórico-metodológica de uma categoria relevante nocontexto da obra, que é a ideologia.

O liberalismo-conservador: fundamentos teóricos ereceituário político desde o século XVIII

5 O livro de Baqués, lançado em 2017, enfatiza a continuidade histórica na formulação, naação política e nas formas de influenciar a realidade e a cultura, por meio da difusão devalores morais do conservadorismo. Essa continuidade histórica, segundo o autor, faz-se apesar das diferentes posturas dos autores que articulam esse pensamento social,através de referenciais comuns entre os conservadores que, embora modificados aolongo do tempo, se reafirmam em argumentações que sedimentam a sua rearticulaçãonesse mesmo tempo. Isto é o que o autor denomina fundamentos teóricos, ou seja,aquilo aqui se entende, com base nos referenciais da tradição marxiana, o cimento quesustenta a parede histórica da apologia burguesa ao modo de produção.

A hipótese que proponho (a primeira hipótese desta pesquisa), em relação aos seusargumentos, é que o conservadorismo moderno tem um “núcleo duro” doutrináriosuficientemente compacto e homogeneo como para poder falar de que estamos ante umaideologia consolidada. Portanto, o meu trabalho consistirá na busca e descoberta, quandoapropriado, do que poderíamos definir como o “denominador comum” de todas estascorrentes. (Baqués, 2017: 57; itálico no original)1


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6 O autor move-se pelo objetivo de compreender o conservadorismo contemporâneo, emparticular o americano e, para isso, remete para a trajetória dos principaisformuladores desse pensamento, deixando clara a sua perspectiva de análise: “Mas, poroutro lado, recuso-me a pensar o conservadorismo moderno prestando atenção apenasa autores e obras escritos no contexto da crise do petróleo dos anos setenta [do séculoXX]” (ibidem: 50), e segue com a argumentação:

[...] a segunda hipótese a ser demonstrada nesta análise é que as verdadeiras raízes doconservadorismo moderno devem ser buscadas em algum ponto na “encruzilhada liberal-conservadora”, uma encruzilhada que existe há quase três séculos e que, muitoparticularmente, pode ser encontrada no seio da Ilustração escocesa. (Baqués, 2017: 62;itálico e negrito no original)

7 Em outras palavras, o autor propõe-se realizar uma radiografia da ideologia liberal-conservadora. Baqués analisou o pensamento de seis autores clássicos, situados entre osséculos XVIII e XIX, e seis contemporâneos, do século XX. A partir do posicionamentodesses autores procurou construir um tipo ideal, no sentido weberiano, buscandochegar ao que considera o “núcleo duro” do conservadorismo. E, sem perder de vista asespecificidades, propõs-se a demonstrar as pequenas diferenças dos diversos autores,afirmando não haver contradição entre elas. Aos autores considerados clássicos – DavidHume, Adam Smith e Adam Ferguson – adicionou pequenos detalhes da obra deEdmund Burke e Alexis de Tocqueville, e considerou que o pensamento político deHerbert Spencer remete para as ideias libertárias num quadro que classificou deanarco-capitalismo ou anarquismo “de direita”. Entre os contemporâneos, consideroucomo sendo conservadores Friedrich Hayek, Michael Oakeshott, Michael Novak e IrvingKristol e como libertários ou anarco-capitalistas Robert Nozick e Murray N. Rothbard.

8 Tendo em conta essa tipificação para situar o posicionamento dos conservadores,Baqués acredita ser possível demonstrar a continuidade entre clássicos econtemporâneos e, também, os fundamentos teóricos desse pensamento social. De umlado, ele situou os defensores do liberalismo social e, de outro, as formas de expressãomais recentes, como os neoconservadores americanos, como o movimento Tea Party –organizado no interior do Partido Republicano nos Estados Unidos da América – e/ou ospopulismos “de direita”, salientando os elementos que dão continuidade à“cosmovisão” ou à ideologia conservadora.

9 O objetivo principal da obra de Baqués (2017) é demonstrar que há autores que podemser diretamente definidos como liberais-conservadores e que o liberalismo-conservadorcontém um corpo teórico suficientemente denso para ser considerado uma ideologiacapaz de colocar perguntas e oferecer respostas que competem com alternativas comoo liberalismo social ou radical, a social democracia, o comunismo, o fascismo, etc. Osegundo objetivo é demonstrar que o liberalismo-conservador não é uma mera reaçãocontra a ideia de progresso. As origens do liberal-conservadorismo remontam àRevolução Francesa e podem, pois, ser vistas como derivadas de outra postura, queoferecia uma leitura própria de natureza humana, da filosofia da história, da liberdadeou da igualdade, dos valores e do papel do Estado na vida das pessoas.

10 A análise do pensamento dos autores fez-se a partir de um conjunto alargado devariáveis, capazes de configurarem um tipo ideal de liberalismo-conservador: 1)filosofia da história, 2) racionalismo e política, 3) moral universal versus moraiscontextualizadas, 4) teoria do direito, 5) democracia, 6) papel do Estado (relação entreEstado e mercado) e 7) sistema de transmissão de valores. A partir delas, Baqués faz


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uma análise comparativa entre os seis autores clássicos e os seis contemporâneos,considerando que as três primeiras variáveis respondem aos fundamentos teóricosadotados pelos autores, a quatro e a cinco aos valores nucleares da ideologia, e a seis e asete a questões relativas à prática política.

11 Sem detalhar os pormenores da análise realizada pelo autor, tentamos expor a suasíntese, quanto à definição de tipo ideal do liberalismo-conservador. Em relação àsegunda hipótese, ou seja, as verdadeiras raízes do conservadorismo moderno, Baquésconsidera que ela pode ser demonstrada em dois sentidos: no tempo e no espaço, ouseja, observa coincidências nas obras de Hume, Hayek e Kristol; ou como elementos decontinuidade entre aqueles que foram, por ele, considerados “ilustrados escoceses”conservadores, e os modernos, como, de um lado, Hume, Adam Smith e Adam Fergusone, de outro, Hayek, Oakeshott, Kristol e Novak.2

12 Detalhando um pouco mais a análise de Baqués (2017: 538) quanto à primeira hipótese,que o conservadorismo moderno se constituiu como uma ideologia consolidada, elemostra existir um núcleo comum compartilhado entre as diferentes famílias ideológicasque compõem o conservadorismo moderno. Entre os autores, identifica mais oselementos que os unem do que os que os diferenciam e estes não afetam o modelo desociedade defendido por todos. Nas seis primeiras variáveis analisadas, indica Baquésserem comuns vários elementos de conexão no que concerne aos aspectos teóricos e,também, da ação política. Quanto à variável 7, todos adotam um discurso que serve, naspalavras de Baqués, como “cimento social”, embora em Kristol e Novak estejam maispresentes os argumentos de uma “crise moral”, do que em Hayek e Oakeshott. Nasequência da análise, Baqués interroga-se se o pensamento é “liberal” ou “conservador”e responde que é ambas as coisas:

[...] uma ideologia “liberal-conservadora” é capaz de integrar desde o início [...]elementos prórpios dessas duas grandes caixas de alfaiate [algo onde cabe tudo]. Enão apenas, como se foi vendo, no que diz respeito à questão de buscar a “moralmais adequada para o capitalismo”, mas também, é claro, em relação às outrasquestões levantadas, sem exceção. (ibidem: 539)

13 Baqués destaca, na análise das variáveis adotadas, o distanciamento dos libertários. EmRothbard, tal distanciamento dá-se nas variáveis 1, 2, 3, 5 e, em parte, nas 6 e 7, sendoque identifica, às vezes, aproximações de alguns autores classificados nessa perspectiva,nas variáveis 4 e 6. Em Nozick, há maior aproximação ao liberalismo-conservador e,mesmo considerando que no passo a passo da análise seja difícil demonstrar, háaproximações a Hayek.

14 Portanto, para Baqués, há evidentes afinidades em nove dos autores analisados, quepodem ser considerados próximos do liberalismo-conservador. Quanto a Spencer, háreservas nesse sentido; Nozick mostra ter pontos de coincidência; e em Rothbard existeum maior distanciamento, o que permite concluir que as maiores aproximações se dãoentre os autores que não são considerados libertários.

15 Tendo em vista, então, a aproximação entre os clássicos Burke e Tocqueville, assimcomo entre os contemporâneos Hayek, Oakeshott, Kristol e Novak, e a aproximação emalguns pontos de Spencer e Nozick, Baqués explicita o tipo ideal construído sobre oliberal-conservadorismo, apontando as seguintes características:

alguma defesa da teoria da evolução, com certa tendência para uma visão “naturalista”, oque, supostamente, retiraria a possibilidade de um posicionamento político;

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visão do ser humano como ignorante por natureza, descarte da possibilidade de decisõesracionais; mas admissão do uso de uma racionalidade instrumental que leve o ser humano auma melhor adaptação aos fins predeterminados, derivados do processo evolutivo;teoria do direito baseada na primazia da propriedade privada, da liberdade negativa e daigualdade perante a lei;moral e direito referenciados na retórica dos direitos naturais; e relativismo moral com basena procura de uma proximidade com o jusnaturalismo e o positivismo;suspeita da incompatibilidade entre democracia e proteção dos direitos e/ou instituiçõesresponsáveis pela ordem espontânea da evolução, com aceitação formal da democraciarepresentativa e recusa de qualquer prática participativa;quanto ao Estado, por um lado, há perspetivas que recusam a justiça social e desautorizampráticas redistributivas, apelando à benevolência privada de cunho caritativo; em geral,admissão das ajudas públicas aos pobres que não podem valer-se a si próprios, estendendo-se a ajuda, às vezes, a todos os indivíduos que necessitam. Porém, quando ocorre essasegunda postura, as ajudas não se justificam pelo respeito a direitos desses sujeitos, mas pelasalvaguarda dos direitos dos demais, perante possíveis atos de “desespero” daqueles;apelo às religiões e ao nacionalismo, o que reforça a “moral capitalista”.

16 Baqués destaca que a relação existente entre o moderno conservadorismo e essaspráticas é meramente instrumental. Delas resultam uma dupla função: atuam como“cimento social”, para garantir a paz social, inclusive em crises prolongadas econtribuem para diminuir o impacto que o excesso de individualismo, hedonismo/consumismo tem sobre a “moral capitalista”. Para alguns autores analisados, acontinuidade do capitalismo depende da sobriedade e do controle moral requeridos.

Análise dos fundamentos do conservadorismo eideologia

17 Uma questão em particular merece ser considerada na leitura da obra de Baqués (2017):a da sua remissão aos entendimentos do liberalismo-conservador como ideologia, ouseja, como cosmovisão (Weltanschauung) ou visão de mundo. Nesse sentido, chamamos aatenção ao amplo debate que envolve a questão. Referimo-nos a Iasi, que recupera essedebate desde as formulações de Hegel sobre os processos de externalização, a partir doqual se tornou evidente, na relação entre o que se configura como objetivo e subjetivo,ocorrer um processo de estranhamento, isto é:

Nossa consciência se externa na efetividade do mundo fora de nós, mas o idealismoobjetivo de Hegel, compreende esta efetivação (Verwirklichung) da consciência nomundo como algo real (uma efetividade inabalável) que ganha uma independênciaem relação à consciência mesma que o produziu, levando, necessariamente, aoprocesso de estranhamento. (Iasi, 2014: 98)

18 Indica Iasi (2014), que os avanços de Marx e Engels quanto a mesma questão, deram-sepor terem decifrado que nem toda objetivação e externalização implicam oestranhamento, atribuindo então a sua explicação, na sociedade capitalista, àmercadoria. Logo, a questão do estranhamento, nessa perspectiva, não está situada naconsciência humana, mas na objetividade das relações.

19 Ainda segundo Iasi (ibidem: 101), Marx e Engels também demonstraram que “Os seresprojetam as suas representações para fora de si mesmos e elas acabam se voltandocontra eles como uma força estranha que os controla”, o que exige compreender os

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indivíduos como seres sociais, inseridos em determinadas forças produtivas e relaçõessociais de produção. Nesse sentido, o debate levado por Marx (1997) que desloca aanálise da religião para o Estado, demonstrando que nas relações de produção,mediadas pela mercadoria, ocorre um movimento que às vezes gera a inversão dasexplicações sobre a realidade: “Fica evidente que os autores não tratam a ideologiacomo mero conjunto de representações ideais, ou uma visão de mundo, mas como umainversão” (Iasi, 2014: 103). Quanto ao estranhamento resultante do processo, Iasianalisa que o fundamento do caráter histórico do ser social e das suas dimensõesontológicas produzem novas necessidades e, também, se associam a determinada formade produção da vida e, nesse contexto, apresentam singularidades em sua existência.

20 A linguagem e a consciência podem ser tomadas como momentos constitutivos dasingularidade humana, pois, nesse âmbito, operam as distinções entre as dimensõesmateriais e espirituais. Ocorrem os “reflexos ideológicos” ou “sublimações necessárias”,em que a consciência se emancipa do mundo. Assim, as representações “[...] expressamuma necessidade, mesmo e principalmente, através de seu caráter de inversão, deocultamento, de estranhamento” (ibidem: 106) e, portanto, há uma distinção entre asformas de consciência e a ideologia, o que leva Iasi a compreender, que para Marx eEngels, “toda ideologia é uma forma de consciência; no entanto, nem toda forma deconsciência é ideológica” (ibidem).

21 Nesse sentido, a ideologia presente na estratégia conservadora, a nosso ver, é a base desustentação histórica, como força política, de reprodução e de ampliação do capital, ou,como de uso frequente entre marxianos, constitui-se em uma apologia burguesa àcontinuidade histórica do capitalismo. Portanto, o entendimento do pensamentoconservador, como movimento que se articula no contrário das conquistas possíveispostas na modernidade, torna-se para nós mais consistente. Conforme Baquésdemonstra, os elos comuns entre o pensamento conservador, apresentado pela análisedos autores que compõem o quadro histórico de sua trajetória, revelam uma doutrinacoerente. Posto na Revolução Francesa, no final do século XVIII, tal pensamento socialarticula-se e reproduz-se historicamente na proximidade, maior ou menor, com oliberalismo, de acordo com as necessidades históricas conjunturais e o que se revelamais ou menos evidenciado nas posturas de um ou outro autor situado nessepensamento social.

22 Assim, compreender tal movimento como um processo que compõe a decadênciaburguesa, parece-nos bastante apropriado, visto que o seu caráter reacionário aosavanços do desenvolvimento se fundiu com as justificativas da continuidade históricado capitalismo. A burguesia abriu mão das conquistas do Iluminismo para seguir emconjunto com forças que, em primeiro momento, tentaram aniquilar odesenvolvimento histórico de uma determinação posta na transição do modo deprodução feudal ao capitalismo. A base de sustentação de tal pensamento constitui-senas forças produtivas; entretanto, conservadores e liberais lançam mãoreiteradamente, ao longo dos séculos, de argumentos situados no plano da linguagem eda consciência, operando com recursos como aqueles adotados nas argumentaçõesassentes nos moralismos, como estratégia de sustentação da sociabilidade burguesa.Porém, a consciência é fruto da situação objetiva de sua condição.

23 E para seguir com as argumentações sobre ideologia, Löwy defende que “[...] existempoucos conceitos na história da ciência social moderna tão enigmáticos e polissémicosquanto o de ‘ideologia’ [...]” (1998: 9-10). Para dizer de forma simples, o autor explica,


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demonstrando a invenção do termo ideologia por Destutt de Tracy, em 1801; a suaadoção por Napoleão Bonaparte; e a forma como Lenine a difundiu: “[...] a ideologiadesigna o conjunto das concepções de mundo ligadas às classes sociais, incluindo omarxismo” (Löwy, 1998: 10; itálicos no original). Löwy destaca ainda a confusão eambivalência ocorrida no debate sobre ideologia, não só no debate entre autores, nosseus posicionamentos, podendo inclusive se encontrar tal ambivalência em uma únicaobra.

24 Quando Löwy analisa a obra Ideologia e Utopia de Karl Mannheim, ele discorda sobre aforma como foram reunidas as duas categorias e ambas consideradas como “falsaconsciência”,3 entretanto, considera que a forma como Mannheim entende ideologia:“[...] uma forma de pensamento orientada para a reprodução da ordem estabelecida”(1998: 11) parece ser apropriada por conservar a dimensão crítica do termo, como emMarx. O autor conclui que o que Mannheim considerou “ideologia total” – e que podeser ideológico ou utópico –, corresponde ao conceito de Weltanschauung, ou seja, a umavisão social de mundo, pois,

[...] o que ele [Mannheim] designa não é, por si só, nem “verdadeiro” nem “falso”,nem “idealista” nem “materialista” (mesmo sendo possível que tome uma destasformas), nem conservador nem revolucionário. Ele circunscreve um conjuntoorgânico, articulado e estruturado de valores, representações, idéias e orientaçõescognitivas, internamente unificado por uma perspectiva determinada, por um certoponto de vista socialmente condicionado. (ibidem: 12-13; itálicos no original).

25 E para finalizar, Löwy acrescenta que, ao Mannheim incorporar social ao conceitoideologia, retira a possibilidade de ser entendido na relação com o cosmos ou ànatureza enquanto tais, mas ao “[...] conjunto relativamente coerente de idéias sobre ohomem, a sociedade, a história, e sua relação com a natureza”; e assim sendo, a visão demundo liga-se “[...] aos interesses e à situação de certos grupos e classes sociais”(ibidem: 13). Por isso, as visões de mundo podem ser ideologias e podem combinar-se aelementos utópicos, pois em dado conjuntura pode ser utopia e em outra circunstânciahistórica, manifestar-se como ideologia.

26 Observa-se, portanto, primeiro, que o liberalismo-conservador estudado por Baqués(2017) constitui uma das estratégias ideológicas que justificam a ampliação das relaçõessociais de produção em bases capitalistas; e, depois, que as consequências nefastas queo neoliberalismo trouxe e continua a trazer, assumem, na atual conjuntura, umahegemonia que o conduz de forma conservadora e também reacionária.

BIBLIOGRAFIA

Baqués Quesada, Josep (2000), El neoconservadurismo: fundamentos teóricos y propuestas políticas. Barcelona: Anagrafic.

Baqués, Josep (2017), El liberalismo-conservador. Fundamentos teóricos y recetario político, ss. XVIII-XX. Barcelona: Thomson Reuters.

Coutinho, Carlos Nelson (2010), O estruturalismo e a miséria da razão. São Paulo: Expressão Popular.


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Iasi, Mauro Luis (2014), “Alienação e ideologia: a carne real das abstrações ideais”, in Marcos delRoio (org.), Marx e a dialética da sociedade civil. São Paulo/Marília: Cultura Acadêmica Editora,95-124.

Lima, Kátia Regina de S. (2002), “Organismos internacionais: o capital em busca de novos camposde exploração”, in Maria Lúcia Wanderley Neves (org.), O empresariamento da Educação. Novoscontornos do Ensino Superior no Brasil nos anos 1990. São Paulo: Xamã, 41-64.

Löwy, Michael (1998), “Introdução”, in As aventuras de Karl Marx contra o Barão de Münchhausen.Marxismo e positivismo na sociologia do conhecimento. São Paulo: Cortez, 7-14 [6.ª ed.].

Lukács, Georg (1981), “Para uma crítica marxista da sociologia”, in Sociologia. São Paulo: Ática,109-172. Tradução de José Paulo Netto e Carlos Nelson Coutinho.

Marx, Karl (1997), Para a questão judaica. Lisboa: Avante.

Mirales, Rosana (no prelo), “A produção teórica sobre o conservadorismo no Serviço Social”, PraiaVermelha, 29(2), 715-740.

NOTAS1. As traduções da obra de Baqués foram realizadas pela autora. 2. No que diz respeito a Burke, Baqués destaca que existe um encadeamento entre ambos osdiscursos conservador e liberal. Quanto a Tocqueville, ele considera o seu pensamento um“denominador comum”, quando tomadas para análise as variáveis mais orientadas para a práticapolítica (3, 4, 5, 6 e 7), e considera que, com as alterações que o próprio autor promoveu na suaobra, relacionadas com a providência e a negação do cartesianismo no âmbito político, tornou-seum “pensador-ponte” entre o conservadorismo e o liberalismo. Spencer, por sua vez, distancia-sede vários pensadores que foram considerados para análise, nas variáveis 1, 3 e 7. Contudo, hácoincidências relativas às variáveis 2, 4 e 6, e diferencia a sua análise quanto à variável 5.3. “Quanto ao conceito de “falsa consciência”, este nos parece inadequado porque as ideologias eas utopias contêm, não apenas as orientações cognitivas, mas também um conjunto articulado devalores culturais, éticos e estéticos que não substituem categorias do falso e do verdadeiro.”(Löwy, 1998: 12).

RESUMOSO debate aqui proposto insere-se numa preocupação assumida em estudos anteriores quanto aoimpacto da guinada conservadora no Serviço Social e inspira-se na obra de Josep Baqués,intitulada El liberalismo-conservador. Fundamentos teóricos y recetario político ss. XVIII-XX. Propõe-se,a partir do contributo do autor nesta obra, realizar uma análise comparativa das várias noções deideologia – aspecto recorrente nas reflexões críticas desenvolvidas em estudos e pesquisas sobreos fundamentos do conservadorismo. A busca do entendimento sobre as metamorfosesadquiridas por esse pensamento social nos diferenciados contextos históricos é confirmada pelaobra de Baqués, que identifica uma tendência de aproximação do conservadorismo aoliberalismo.


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The debate proposed here is part of a concern assumed in previous studies about the impact ofthe conservative shift on social work and it is inspired by Josep Baqués’s study, El liberalismo-conservador: Fundamentos teóricos y recetario político ss. XVIII-XX. Based on Baqués’s contribution,this article presents a comparative analysis of the notions of ideology – a recurring aspect incritical reflections in studies and research on the foundations of conservatism. The search for anunderstanding of the metamorphoses of this form of social thought in different historicalcontexts is confirmed by Baqués’ work, which identifies a tendency for conservarism to movecloser to liberalism.

ÍNDICE

Keywords: conservatism, foundations, liberalism, politics, theoryPalavras-chave: conservadorismo, fundamentos, liberalismo, política, teoria

AUTOR

ROSANA MIRALES

Universidade Estadual do Oeste do Paraná, Campus de ToledoRua da Faculdade, 645 – Jardim La Salle, CEP: 85903-000, Toledo-Paraná, [email protected]


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