Hans Dubois
The crisis has had an important impact on hugely complex healthcare systems, interacting with, and sometimes dominated by, other major drivers of change. Maintaining access to healthcare has become a challenge for policymakers and care providers in the wake of the crisis, with reduced supply of services and a rise in demand for some healthcare services. A new report by Eurofound, the Dublin-based EU social research agency, explores which population groups have experienced reduced access to healthcare since the crisis and looks at examples of measures taken to maintain access for groups in vulnerable situations.
Reduced supply and increased demand
The report Access to healthcare in times of crisis shows that the crisis has led to reduced supply of services via reduced budgets, closure of healthcare services and restrictions on hiring staff. It has also resulted in increased demand for certain healthcare services. Most notably, increased job and housing insecurity have been associated with increased mental health problems.
But increased demand for certain public healthcare services has not only come from increased medical need. For instance,
- people are turning to healthcare services for non-health problems, either because other services have been cut or they do not know whom otherwise to turn to;
- patients who can no longer afford fee-charging private services or private insurance are making a move to the public sector.
Reduced access for new groups
Even in the richest EU Member States, many people report difficulties accessing healthcare because of cost, distance or waiting times (see map).
Proportion of people reporting difficulty accessing healthcare in the EU (%)
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For many people the crisis has made access to healthcare services more difficult. Partly this has been the consequence of government cuts, with reduced coverage of services and increased copayments (where service users pay part of the cost themselves). But, even when cuts were absent, people have experienced reduced access because of the crisis, as a result of reduced disposable income or increased medical need.
Difficulties in accessing healthcare have long been more common among certain population groups. While there is great heterogeneity within these groups, they include for example people living in remote areas, migrants and homeless people. Cuts in support services for groups in particularly vulnerable situations, such as social workers who help people find their way through the healthcare system (Slovenia) or migrant mediators (Portugal), have made the situation of those groups even more vulnerable.
The crisis has also affected groups that were rarely considered as being in a vulnerable situation due to unemployment among young and middle-aged men who lost jobs, and over-indebtedness among young families. The crisis has shown that anybody’s situation can become vulnerable. For example, some people have lost benefits or a job that came with health insurance, while others who have migrated to find work have found themselves in a new situation in a new country and often being unaware of entitlements
Looking beyond laws and numbers
In discussing the impacts of the crisis, there has been much emphasis on laws and numbers. These are key, but it is important to look beyond them.
Many service providers report that they do not implement required copayments for people who can clearly not afford them, or provide care to uninsured patients. Such ‘leniency’ by service providers has played an important role in maintaining access, but there has also been less financial room for it. On the down side, leniency can nullify attempts to steer patients to more appropriate, less expensive care. For example, in some countries (Greece, Portugal), rather than using primary care, patients attend emergency services where copayments are less likely to be enforced.
A second example is nursing homes (with healthcare facilities). There are reports of decreased demand (Hungary, Latvia, Slovenia), regardless of ageing societies. However, this is caused in part by older people staying in the community to contribute with their pensions to household income of unemployed relatives.
Third, in some countries the move from the private to the public sector dominated (Cyprus, Greece, Spain), but simultaneously there was a reverse move from public to private by people in these countries. This is masked by aggregated data. People have moved from public to private healthcare because of decreased price differences, perceptions of reduced quality of public services and longer-standing trends. The move from public to private has dominated in some countries (Bulgaria, Romania, Sweden).
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Maintaining access
Governments and service providers have tried to face the challenge of maintaining access to healthcare.
- Healthcare providers have economised to maintain access, decreasing spending for example on utilities, food and ICT. The risk is that this may affect the quality of core services.
- There has also been a focus on ensuring basic service delivery, such as scaled-down replacement services, when a service provider is closed. In cases in Latvia, Romania and Sweden, primary care has been strengthened. In Greece, Slovenia and Spain, several mental healthcare providers have implemented group sessions for patients with crisis-related problems.
- The crisis has also accelerated trends to steer people to less expensive forms of long-term care and healthcare. Examples are deinstitutionalisation of people with disabilities or mental health problems and keeping older people out of nursing home (health)care and hospitals.
- Acceleration of ICT applications, such as distant diagnosis of images sent by GPs to specialists, has improved access for example in remote areas in Luxembourg, Portugal and Romania.
In short, while maintaining access, ‘mitigating measures’ come with risks. Financial pressure is not new for most healthcare providers, and is unlikely to disappear altogether, but when pressure decreases, it is important to reassess these mitigating measures.
Working paper: Impacts of the crisis on access to healthcare services in the EU (2013)
Discussing the dimensions of access to healthcare and data analysis of the impacts of the crisis.
Research report: Access to healthcare in times of crisis (2014)
In-depth analysis of the impacts of the crisis on access to healthcare in Member States, identification of groups impacted by the crisis, examples of mitigating measures and evidence from 31 case studies.
Hans Dubois is research manager in the social-policies unit at Eurofound in Dublin.