Abstract

Introduction

Despite the overall increase in living standards in the 20th century and the introduction of universal health systems, many studies have identified persistent inequalities in all the industrialized countries. Such inequalities have been observed even in countries that are considered “more equitable”, like Great Britain, the Netherlands, and Sweden, whose governments have a long tradition of analyzing and dealing with health inequalities ¹1. Lahema E, Rahkonen O. Introduction. Soc Sci Med 1997; 44:721-2.^,22. Eikemo TA, Huisman M, Bambra C, Kunst AE. Health inequalities according to educational level in different welfare regimes: a comparison of 23 European countries. Sociol Health Ill 2008; 3:565-82.. The World Health Organization (WHO) has acknowledged that among the European countries there are “unacceptable inequalities in health status between different social groups in society” ³3. World Health Organization. The European health report 2002. Copenaghen: World Health Organization; 2003. (p. 135), while pointing to the central role of economic, social, environmental, and institutional determinants in the production and development of health inequalities ⁴4. World Health Organization. World conference on social determinants of health: meeting report. Rio de Janeiro: World Health Organization; 2011.. In this sense, social inequalities in health are still a critical issue for the majority of European countries, as evidenced by the British study Fair Society, Healthy Lives. The Marmot Review⁵5. Marmot M. Fair society, healthy life. The Marmot review. London: UCL Institute of Health Equity; 2010., and the results of the European Commission’s working group published in the Report on Health Inequalities in the European Union⁶6. European Commission. Report on health inequalities in the European Union. Commission staff working document. Brussells: European Commission; 2013.. The Report points to a significant reduction in health inequalities as measured by life expectancy and infant mortality, while identifying the persistence of some forms of health inequality between various social groups and the different regions and member states.

In the countries of Southern Europe, specifically Spain, Greece, Italy, and Portugal, although the reforms of the 1970s and 1980s introduced universal national health services and the concern for reducing geographic imbalances between different regions, social inequalities in health only became a critical issue in the late 1990s. The four countries still lack a consolidated tradition of analyzing and dealing with social inequalities in health ⁷7. European Union. Health inequalities in the EU - final report of consortium. Brussells: European Commission Directorate-General for Health and Consumers; 2013., unlike the countries of Northern Europe.

However, the issue of health inequalities became a priority again in the countries of Southern Europe starting in 2010-2011, when (although with different degrees of severity) the four countries began to feel the first effects of the financial crisis of 2008 and the austerity policies imposed by the Troika (European Commission, European Central Bank, and International Monetary Fund) ⁷7. European Union. Health inequalities in the EU - final report of consortium. Brussells: European Commission Directorate-General for Health and Consumers; 2013.^,88. Thomson S, Figueras J, Evetovits T, Jowett M, Mladovsky P, Maresso A, et al. Economic crisis, health systems and health in Europe. Maidenhead: Open University Press; 2015.^,99. Petmesidou M, Guillén AM. Can the welfare state as we know it survive? A view from the crisis-ridden South European periphery. South Eur Soc Polit 2014; 19:295-307..

Various studies have identified the impact of the economic crisis on the most vulnerable population groups, with increasing rates of mental health disorders (e.g., anxiety and depression) and a rise in suicides ⁸8. Thomson S, Figueras J, Evetovits T, Jowett M, Mladovsky P, Maresso A, et al. Economic crisis, health systems and health in Europe. Maidenhead: Open University Press; 2015.^,1010. De Vogli R. The financial crisis, health and health inequities in Europe: the need for regulations, redistribution and social protection. Int J Equity Health 2014; 13:58.. Such effects have already been observed in Greece, Spain, Ireland, Italy, and Portugal ¹¹11. Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu S, Stuckler D, et al. Financial crisis, austerity, and health in Europe. Lancet 2013; 381:1323-31.^,1212. Ruiz-Pérez I, Bermudez-Tamayo C, Rodríguez-Barranco M. Socio-economic factors linked with mental health during the recession: a multilevel analysis. Int J Equity Health 2017; 16:45.. According to several studies, the increase in social inequalities constitutes one of the principal side effects of the structural adjustment policies adopted in the Southern European countries ¹⁰10. De Vogli R. The financial crisis, health and health inequities in Europe: the need for regulations, redistribution and social protection. Int J Equity Health 2014; 13:58.^,1313. Escolar-Pujolar A, Bacigalupe A, San Sebastian M. European economic crisis and health inequalities: research challenges in an uncertain scenario. Int J Equity Health 2014; 13:59-61..

The current study resulted from a non-systematic literature review based on the scoping review technique proposed by Arksey & O’Malley ¹⁴14. Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005; 8:19-32. and organized in five phases: (i) identification of the research questions; (ii) search for relevant studies; (iii) selection of studies; (iv) qualitative data description; and (v) collection, summary, and report of the results. A total of 74 publications were analyzed for this purpose. The collected material resulted from the search performed in Web of Science, PubMed, Scopus, SciELO, and Google Scholar, using the terms “health inequalities”, “social inequalities in health”, “health system reforms”, “impact of the economic/financial crisis”, and “countries of Southern Europe”. The search was done in English and the national languages of the four countries.

The current article begins with a brief contextualization of the welfare state in the countries of Southern Europe, highlighting the principal specificities and differences in relation to other European welfare state regimes. The article then describes the health systems in Greece, Spain, Italy, and Portugal, focusing on the reform processes and main health inequalities in countries before and during the economic crisis. The health inequalities will be discussed next, underscoring common tendencies and differences between the four countries.

Study context

Concerning the welfare state in advanced capitalist societies, Esping-Andersen ¹⁵15. Esping-Andersen G. The three worlds of welfare capitalism. Cambridge: Polity Press; 1990. identified three “welfare regimes” that were consolidated during the expansion of Keynesian capitalism: Social Democratic, in the Scandinavian countries; Conservative, in other countries of Continental Europe; and Liberal, in the Anglo-Saxon countries. Replying to various criticisms, the author argued that the welfare state in Southern Europe is a variant of the Conservative type of regime ¹⁶16. Esping-Andersen G. Social foundations of postindustrial economies. Oxford: Oxford University Press; 1999..

According to several authors, Esping-Andersen’s analysis failed to highlight the specificities and characteristics proper to the welfare state in the countries of Southern Europe, and they defended a new approach to identify the distinctive aspects of the social protection systems in these countries ¹⁷17. Ferrera M. The 'southern model' of welfare in social Europe. J Eur Soc Policy 1996; 6:17-37.^,1818. Rhodes M. Southern European welfare: identiy, problems and prospects. South Eur Soc Polit 1998; 1:1-22.^,1919. Andreotti A, García S, Gomez A, Hespanha P, Kazepov Y, Mingione E. Does a southern model exist? Journal of European Area Studies 2001; 9:43-62.^,2020. Silva PA. O modelo de welfare da Europa do sul. Sociologia, Problemas e Práticas 2002; 38:25-59.^,2121. Bambra C. Going beyond the three worlds of welfare capitalism: regime theory and public health research. J Epidemiol Community Health 2007; 61:1098-102.^,2222. Guillén AM, León M, editors. The Spanish welfare state in European context. Farnham: Ashgate; 2011.. According to Ferrera ¹⁷17. Ferrera M. The 'southern model' of welfare in social Europe. J Eur Soc Policy 1996; 6:17-37., one of the principal characteristics of the Southern model in social Europe was the introduction of dualist social protection during the period of great economic expansion (1945-1975), with highly generous provisions for the central market categories (public employees and workers in large industries) and modest protection schemes for peripheral categories (precarious workers, self-employed, and employees of small companies). In this shaping of the welfare state, the family model, characterized by close kinship ties and inter-generational solidarity ²³23. Naldini M. Le politiche sociali in Europa. Trasformazioni dei bisogni e risposte di policy. Roma: Carocci; 2006.^,2424. Karamessini M. Continuity and change in the Southern European social model. Int Labour Rev 2008; 147:43-70.^,2525. Tavora I. The Southern European social model: familialism and the high rates of female employment in Portugal. J Eur Soc Policy 2002; 22:63-76.^,2626. León M, Migliavacca M. Italy and Spain: still the case of familistic welfare models? Popul Rev 2013; 25:25-42., assumes the role of compensation and reduction of risks and needs through the provision of welfare, primarily ensured by women. This characteristic, typical of the countries of Southern Europe, has been identified as a central element in what has been called the “welfare society” ²⁷27. Hespanha P. The welfare society and the welfare state. The Portuguese experience. In: Roche M, van Berkel R, editors. European citizenship and social exclusion. Aldershot: Ashgate; 1997. p. 169-83..

In addition to the historical and sociopolitical factors that influenced the development of the welfare state in the countries of Southern Europe, other factors definitely contributed to shaping them as the fourth welfare state model: corporatism, accentuated by the experiences with authoritarian governments, the influence of the Catholic Church, and fierce partisan political competition, as discussed by various authors ¹⁵15. Esping-Andersen G. The three worlds of welfare capitalism. Cambridge: Polity Press; 1990.^,1717. Ferrera M. The 'southern model' of welfare in social Europe. J Eur Soc Policy 1996; 6:17-37.^,1818. Rhodes M. Southern European welfare: identiy, problems and prospects. South Eur Soc Polit 1998; 1:1-22..

Another distinctive trait of the social protection model in Southern European is the health systems characterized by a universalist theoretical approach, despite their institutional fragmentation ¹⁷17. Ferrera M. The 'southern model' of welfare in social Europe. J Eur Soc Policy 1996; 6:17-37.^,2424. Karamessini M. Continuity and change in the Southern European social model. Int Labour Rev 2008; 147:43-70.^,2828. Bertin G, Carradore M. Differentiaion of welfare regimes: the case of Italy. Int J Soc Welf 2006; 25:149-60.. During the final expansion of the welfare state in the 1970s and 1980s, the four countries of Southern Europe did in fact establish universal national health services based on citizens’ rights and inspired by the Beveridge Model. However, the transition in health systems based on insurance for a national health service occurred at different paces and produced varying levels of coverage in the respective countries ²⁹29. Petmesidou M, Pavolini E, Guillén AM. South European healthcare systems under harsh austerity: a progress-regression mix? South Eur Soc Polit 2014; 19:331-52.. Spain and Italy developed public health systems based more on universalist principles and promoted regionalization of their national health services ³⁰30. Pavolini E, Guillén A, editors. Health care systems in Europe under austerity. Institutional reforms and performance. Basingstoke: Palgrave; 2013.. In Greece, and to a certain extent in Portugal, the health systems remained fragmented between the public and private subsystems, at least in the first phase of the transition ³¹31. Mossialos E, Allin S, Davaki K. Analysing the Greek health system: a tale of fragmentation and inertia. Health Econ 2005; 14 Suppl 1:S151-68.^,3232. Barros PP, Machado SR, Simões JA. Portugal. Health system review. Health Syst Transit 2011; 13:1-156..

The common characteristics of the national health systems in Southern Europe include: (i) incoherence between universalist promises and their actual implementation, especially for financial reasons; (ii) inefficiency and low levels of management competencies that led governments to promote various reforms, purportedly intended to increase the health systems’ efficiency; (iii) the role played by the family and kinship and neighborhood networks, attempting to compensate for the lack of institutional support (support services, especially home care, etc.) to offset the lack of social care provisions under the national health system; (iv) lack of respect for users’ rights under the respective health system, for example patients’ rights and users’ right to information. According to the Euro Health Consumer Index 2015³³33. Health Consumer Powerhouse. Euro Health Consumer Index 2015. Report. http://www.healthpowerhouse.com/files/EHCI_2015/EHCI_2015_report.pdf (acessado em 02/Jun/2016).
http://www.healthpowerhouse.com/files/EH... , health systems in Southern Europe need to close the gap separating them from the Scandinavian countries and other countries of Continental Europe in the area of patients’ rights and users’ right to information; and (v) lack of channels and mechanisms for participation, responsible for the low levels of citizens’ involvement in health decisions ³⁴34. Matos AR, Serapioni M. The challenge of citizens' participation in health systems in Southern Europe: a literature review. Cad Saúde Pública 2017; 33:e00066716..

Despite the limitations and difficulties identified in recent years, Greece, Spain, Italy, and Portugal have reached levels of life expectancy (among other favorable indicators of rising health standards) that place them among the top-ranking countries of the world. The overall improvement in living conditions and healthcare has resulted from socioeconomic development in recent decades and favorable health standards in the Mediterranean countries. Still, these health indicators hide situations of internal heterogeneity, i.e., inequalities in the distribution of material resources, education, social status, and access to healthcare. All this obviously produces disparities in the exposure to important risk factors. In this situation, already quite complex, the impact of the current financial crisis (considering both the direct short-term effects and the indirect medium and long-term effects ³⁵35. Dávila Quintana C, Lopez-Valcárcel B. Crisis económica y salud. Gac Sanit 2009; 23:261-5., resulting from budget cuts in public healthcare systems) may have accentuated the health inequalities, subsequently reducing access to and use of preventive services and further affecting vulnerable individuals with fewer resources and less social capital.

Health systems in the countries of Southern Europe: reform processes and inequalities

This section of the article presents the principal stages in the reform process implemented in the countries of Southern Europe, identifying the various forms of social and geographic inequalities and the reforms’ impact on the production of inequalities. For the analysis of health inequalities, aimed at highlighting differences and similarities between the four countries, six thematic lines were used:

Inequalities and social gradient;

Geographic inequalities and access to health services;

Economic crisis and increase in families’ out-of-pocket health spending;

Reduction in public investment in healthcare;

Health systems’ decentralization;

Impact of economic crisis on the most vulnerable groups.

Spain

With the reestablishment of democracy in 1977, Spain created the Ministry of Health and Social Security, which absorbed the other existing health institutions and services. In 1986, the General Health Law established the National Health System and accelerated the process of transfer of health responsibilities to the country’s 17 Autonomous Communities ³⁶36. Rey del Castillo J. Analisis del origen, situacion y perspectiva de futuro del processo de descentralizacion sanitario espanol. Rev Esp Salud Pública 1998; 1:13-24.. This reform process contributed significantly to the expansion of health coverage. However, various studies have detected geographic inequalities in access to and use of health services, with a pattern of inequality between regions with higher socioeconomic status (in the north), displaying better health indicators, and the south and west, with higher rates of chronic diseases ³⁷37. Gonzáles López-Valcárcel B, Berber Perez P. Desigualdades territoriales en el Sistema Nacional de Salud (SNS) de España. Documento de trabajo. Madrid: Fundación Alternativas 90; 2006..

The Bernat Report had a major impact, underscoring the geographic inequalities in health, stating that “the perception in Spain is that 17 different health management systems coexist” ³⁸38. Soria B. Informe Bernat Soria. Madrid: Abbott Laboratories; 2011. (p. 48), a view based on the observation of differences in the provision of services, coverage, and clinical practice between the 17 Autonomous Communities.

The current financial crisis has certainly not helped relieve this situation. Austerity policies and privatization of services implemented during this period have actually led to an increase in social inequalities both in the use of health services and in health status itself ³⁹39. Bacigalupe A, Martín U, Font R, González-Rabago Y, Bergantiños N. Austeridade y privatización sanitaria en época de crisis: ¿existen diferencias entre las comunidades autónomas? Gac Sanit 2016; 30:47-51..

In addition to geographic inequalities, health inequalities associated with socioeconomic factors such as education, income, and work status have persisted over time ⁴⁰40. Urbanos-Garrido R. Social inequality in health. Measuring the contribution of housing deprivation and social interaction in health. Int J Equity Health 2012; 11:77.. For example, evidence has shown an association between social class and chronic diseases, more prevalent in persons with less schooling, as well as inequalities associated with risk factors like smoking and alcohol consumption ⁴¹41. Dalstra JAA, Kunst AE, Borrell C, Breeze E, Cambois E, Costa G, et al. Socioeconomic differences in the prevalence of common chronic diseases: an overview of eight European countries. Int J Epidemiol 2005; 34:316-26.. Inequalities and risk factors have also increased in the case of obesity, showing a prevalence of 10% among non-manual workers, compared to 18% in manual laborers ⁴²42. Ministério de Sanidad y Política Social. Avanzando hacia la equidade. Propuesta de política para reducir las desigualdades sociales en salud en España. http://www.mspsi.gob.es/profesionales/saludPublica/prevPromocion/promocion/desigualdadSalud/docs/Propuesta_Politicas_Reducir_Desigualdades.pdf (acessado em 10/Mai/2016).
http://www.mspsi.gob.es/profesionales/sa... . There are also class differences in the majority of the cardiovascular risk factors ⁴³43. López-Gonzáles A, Bennasar-Veny M, Tauler P, Aguilo A, Tomás-Salva M, Yañez A. Desigualdades socioeconómicas y diferencias según sexo y edad en los factores de riesgo cardiovasculares. Gac Sanit 2015; 239:27-36.. The recent economic crisis has also been incriminated in rising suicide rates ⁴⁴44. Lopez Bernal JA, Gasparrini A, Artundo CM, McKee M. The effect of the late 2000s financial crisis on suicide in Spain: an interrupted time-series analysis. Eur J Public Health 2013; 23:732-6..

It is important to emphasize the increase in socioeconomic inequalities in health as the result of dual coverage (public and private services) for the most privileged social strata, who have better access to specialists and preventive practices (for example, dental appointments and mammography tests) when compared to other population groups, who tend to use emergency services and primary care more often ⁴⁵45. García-Armesto S, Abadía-Taira MB, Durán A, Hernández-Quevedo C, Bernal-Delgado E. Spain: health system review. Health Syst Transit 2010; 12:1-295..

The private health system has grown steadily since the late 1990s ⁴⁵45. García-Armesto S, Abadía-Taira MB, Durán A, Hernández-Quevedo C, Bernal-Delgado E. Spain: health system review. Health Syst Transit 2010; 12:1-295., a trend that has been even faster since the onset of the current financial crisis. The crisis thus provided an ideal scenario for the Spanish government to promulgate Royal Decree-Law 16/2012, which “breaks with the universalist model, with serious losses or rights” and implements a system based on voluntary insurance, or in the case of unemployment, on social security ⁴⁶46. López-Fernandez LA, Martínez-Millán JI, Ajuria AF, March Cerdá JC, Suess A, Danet DD, et al. Está en peligro la cobertura universal en nuestro Sistema Nacional de Salud? Gac Sanit 2012; 26:298-300.. According to Navarro ⁴⁷47. Navarro V. The social crisis of the Eurozone: the case of Spain. Int J Health Serv 2013; 43:189-92., the substantial cuts in public health are accelerating the growth of private spending, with further segmentation of the Spanish health system, including private healthcare for the wealthier social strata and a public system that treats lower-income strata. According to Legido-Quigley et al. ⁴⁸48. Legido-Quigley H, Otero L, la Parra D, Alvarez-Dardet C, Martin-Moreno JM, McKee M. Will austerity cuts dismantle the Spanish healthcare systems? BMJ 2013; 346:f2363., the current health system reform hides the underlying interest of siphoning public funds to the private sector.

Greece

In 1983, Greece created its National Health Service (Ethniko Systima Ygeias), adopting the principles of universality and equity. The previous health system had been financed by some 300 social security funds. But the reform of 1983 was only implemented partially, and the unification of the social security funds was abandoned, and the Greek health system did not become universal.

The Greek Ministry of Health launched a new reform in 2000, the main objectives of which were decentralization of the system, strengthening primary healthcare, and the establishment of new forms of collaboration between the public and private sectors ³¹31. Mossialos E, Allin S, Davaki K. Analysing the Greek health system: a tale of fragmentation and inertia. Health Econ 2005; 14 Suppl 1:S151-68.. But it only proved possible to partially decentralize the health system, with the creation of 16 regional health authorities. The government was also unsuccessful in inducing the merger of countless health insurance funds, the principal factor leading to inequalities in health. The government’s program also left out the creation of primary care centers in urban areas and the promotion of a family medicine system ⁴⁹49. Petmesidou M, Guillén A. 'Southern style' national health services. Recent reforms and trends in Spain and Greece. Soc Policy Adm 2008; 42:106-24..

By 2010 there were still some 30 insurance funds in Greece. Each fund was subject to its own legislation, with differences, and there were differences in the contribution rates and the conditions for granting benefits, resulting in “inequalities in access to and financing of services”, as pointed out by Economou ⁵⁰50. Economou C. Greece: health system review. Health Syst Transit 2010; 12:1-180. (p. xviii). The Greek government substantially subsidized health plans for public employees and the military ³¹31. Mossialos E, Allin S, Davaki K. Analysing the Greek health system: a tale of fragmentation and inertia. Health Econ 2005; 14 Suppl 1:S151-68., benefits that were steadily reduced as a result of the agreements with the Troika ⁵¹51. Economou C, Kaitelidou DC, Kentikelenis A, Maresso A, Sissouras A. The impact of the crisis on the health system and health in Greece. In: Maresso A, Mladovsky P, Thomson S, Sagan A, Karanikolos M, Richardson E, et al., editors. Economic crisis, health systems and health in Europe, Copenhagen: World Health Organization/European Observatory on Health Systems and Policies; 2015. p. 103-42.. The situation changed in 2011 with the creation of a unified fund, the National Health Services Organization (EOPYY), proposed under various reforms since 1968 but which never made headway. The new fund was designed to serve the vast majority of the population (workers, dependents, and pensioners). But due to the country’s deep crisis, unemployment increased rapidly reaching 27.3% by 2013 ⁵¹51. Economou C, Kaitelidou DC, Kentikelenis A, Maresso A, Sissouras A. The impact of the crisis on the health system and health in Greece. In: Maresso A, Mladovsky P, Thomson S, Sagan A, Karanikolos M, Richardson E, et al., editors. Economic crisis, health systems and health in Europe, Copenhagen: World Health Organization/European Observatory on Health Systems and Policies; 2015. p. 103-42..

Another important factor contributing to inequality is the steady growth of private health spending by Greek families (out of-pocket payments), estimated as the highest in the European Union ⁴⁷47. Navarro V. The social crisis of the Eurozone: the case of Spain. Int J Health Serv 2013; 43:189-92.^,5252. Kaitelidou DC, Kouli E. Greece: the health system in a time of crisis. Eurohealth Observer 2012; 18:12-4.. The significant increase in direct private spending is the most regressive form of financing and has resulted in an increase in inequalities in the Greek health system, particularly affecting the poorest and most vulnerable social groups ⁵³53. Liaropoulos L, Siskou O, Kaitelidou D, Theodorou M, Katostaras T. Informal payments in public hospitals in Greece. Health Policy 2008; 87:72-81.^,5454. Kaitelidou DC, Tsirona CS, Galanis PA, Siskou OC, Mladovsky P, Kouli EG, et al. Informal payments for maternity health services in public hospitals in Greece. Health Policy 2013; 109:23-30..

Although there is no official study on inequalities in access to health services, some studies have analyzed the issue indirectly. According to one such study in 11 countries of the European Union, Greece, Ireland, Italy and the Netherlands show the highest absolute and relative inequality indices in men, and Greece, Spain, and Ireland have the highest indices in women ⁵⁵55. Huisman M, Kunst AE, Mackenbach JP. Socioeconomic inequalities in morbidity among the elderly: a European overview. Soc Sci Med 2003; 57:861-73.. The relationship was also studied between economic status and use of oral health services, emphasizing the association between higher income and more dental consultations ⁵⁶56. Zavras D, Economou C, Kyriopoulos J. Factors influencing dental utilization in Greece. Community Dent Health 2004; 21:181-8..

More recent studies have analyzed the effects of the recent economic crisis on health and healthcare, pointing to increasing rates of mental disorders, suicide, infectious diseases, and deteriorating self-rated health ⁵⁷57. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet 2011; 378:1457-8.^,5858. Simou E, Koutsogeorgou E. Effects of the economic crisis on health and healthcare in Greece in the literature from 2009 to 2013: a systematic review. Health Policy 2014; 115:111-9..

There are also major geographic inequalities in Greece. Some underprivileged regions lack the necessary infrastructure and staff to meet the population’s needs, both in hospitals and rural health clinics. The geographic distribution of private clinics and diagnostic centers is also highly unequal, mostly concentrated in Greater Athens and Macedonia ⁴⁹49. Petmesidou M, Guillén A. 'Southern style' national health services. Recent reforms and trends in Spain and Greece. Soc Policy Adm 2008; 42:106-24..

Italy

The 1978 reform in Italy introduced a universal health system (Servizio Sanitario Nazionale) and proclaimed the promotion of equity and the reduction of geographic inequalities in the supply of services ⁵⁹59. Costa G, Spadea T, Cardano M, editors. Diseguaglianze di salute in Italia. Epidemiol Prev 2004; 28(3 Suppl):1-160.. However, when the country began measuring health differences more systematically in the late 1980s, the inequalities appeared immediately. Longitudinal studies in Torino, Florence, and Livorno ⁶⁰60. Costa G, Faggiano F, editors. L'equità nella salute in Italia: rapporto sulle disuguaglianze sociali in sanità. Milano: Fondazione Smith Kline/Angeli Editore; 1994.^,6161. Cardano M, Costa G, Demaria M, Merler E, Biggeri A. Le disuguaglianze di mortalità negli studi longitudinali italiani. Epidemiol Prev 1999; 23:141-52. showed a linear relationship between rising mortality and increasing social disadvantage, whatever the indicator used, both at the individual level (schooling, social class, housing conditions) and geographic level (poverty rates, income rates, etc.).

According to several studies, the regions of southern Italy have worse disease prevalence rates in all the health dimensions analyzed ⁶²62. Gargiulo L, Sebastiani G, editors. Le condizioni di salute della popolazione. Indagine multiscopo sulle famiglie. Roma: ISTAT; 2002.^,6363. Granaglia E, Compagnoni V. Disuguaglianze sanitarie e mezzogiorno. Roma: Ministero dello Sviluppo Economico; 2007.^,6464. Costa G, Bassi M, Censini GF, Marra M, Nicelli AL, Zengarini N, editors. L'equità in salute in Italia. Secondo rapporto sulle disuguaglianze sociali in sanità. Milano: Fondazione Smith Kline/Angeli Editore; 2014..

Other studies have detected social inequalities in access to primary prevention and early diagnosis ⁶⁵65. Spadea T. La prevenzione primaria e la diagnosi precoce. Epidemiol Prev 2004; 28(3 Suppl):97-102.. Studies consistently show that the risk of dying increases as schooling decreases, both in men and women ⁶⁴64. Costa G, Bassi M, Censini GF, Marra M, Nicelli AL, Zengarini N, editors. L'equità in salute in Italia. Secondo rapporto sulle disuguaglianze sociali in sanità. Milano: Fondazione Smith Kline/Angeli Editore; 2014..

Still other studies have found evidence of unequal distribution in health and disease between native Italians and immigrants. The health inequalities affecting immigrants result mainly from the system of social relations, i.e., in the discomfort resulting from the relationship with the societies receiving the immigrants ⁶⁶66. Perocco F. Trasformazioni globali e nuove disuguaglianze. Il caso italiano. Milano: Franco Angeli; 2012. and in the more precarious and unhealthy working conditions to which the latter are exposed. Health inequalities for immigrant women include: (i) higher incidence of low birth weight newborns; (ii) higher infant mortality; and (iii) less use of prenatal services ⁶⁷67. Tognetti Bordogna M. Nuove disuguaglianze di salute: il caso degli immigrati. Cambio 2013; 3:59-72..

Another critical issue is the health systems’ own responsibility for the production of inequalities ⁶⁸68. Giarelli G, Serapioni M. Les inegalités devant la santé en Italie: un paradoxe aparent? Revue Sociologie Santé 2006; 25:279-90.. According to Costa et al. ⁵⁹59. Costa G, Spadea T, Cardano M, editors. Diseguaglianze di salute in Italia. Epidemiol Prev 2004; 28(3 Suppl):1-160., the main threats come from the new institutional arrangements implemented by the national and regional health systems, referring to the following: (i) possible discrimination introduced by rules providing for new mixed management formats and public-private care; (ii) transfer to the local communities of revenues and management of social services for the elderly, people with disabilities, and users of mental health services, where this decentralization process could increase the geographic inequalities in the availability of resources for social interventions; and (iii) new inequalities in the use of specialized services (especially high-complexity), varying according to social status, while access to primary care remains basically egalitarian.

More recent studies have confirmed the tendency towards proliferation of disparate health systems, influenced by the characteristics of the respective regional social protection systems. Bertin & Carradore ²⁸28. Bertin G, Carradore M. Differentiaion of welfare regimes: the case of Italy. Int J Soc Welf 2006; 25:149-60. identified seven heterogeneous groups of Italian regions as the result of a cluster analysis based on institutional and socioeconomic variables and criteria, e.g., the predominant financing system (public versus private), the role of different actors in the provision of services (government, private, and third sector), and the governance or modality of control for the different regional systems. These developments can contribute to an increase in inequalities in social protection for citizens residing in different regions of the country, including inequalities in access to health services. Granaglia & Compagnoni ⁶³63. Granaglia E, Compagnoni V. Disuguaglianze sanitarie e mezzogiorno. Roma: Ministero dello Sviluppo Economico; 2007. point to significant differences between the regions of the south versus center and north of Italy in relation to infant mortality (5.3% versus 3.3%) and avoidable deaths, such a mortality from diabetes in individuals less than 55 years of age and breast cancer mortality. These data are corroborated by the recent Health Consumer Powerhouse study ³³33. Health Consumer Powerhouse. Euro Health Consumer Index 2015. Report. http://www.healthpowerhouse.com/files/EHCI_2015/EHCI_2015_report.pdf (acessado em 02/Jun/2016).
http://www.healthpowerhouse.com/files/EH... , underscoring marked regional variation in quality of healthcare.

Portugal

Since Portugal established its National Health Service (SNS) in 1979, the country has faced various problems, including underfinancing, concentration of resources in the hospital sector, lack of coordination between primary and secondary care, and inequalities in access, due to the private sector’s strong presence ⁶⁹69. Bentes M, Dias CM, Sakellarides C, Bankauskaite V. Health care systems in transition: Portugal. Copenhagen: WHO Regional Office for Europe; 2004.. An important stage in the reform was ushered in by the Basic Health Law of 1990 and the Statute of the National Health Service of 1993, incorporating some elements of the neoliberal policies in vogue at the time. The larger role assigned to the private sector in the provision of care and financing led to differential access to health services and refocused the problem of inequality.

Another significant stage was the approval of the National Health Plan 2004-2010⁷⁰70. Direcção-Geral da Saúde, Ministério da Saúde. Plano Nacional de Saúde 2004-2010. Lisboa: Direcção-Geral da Saúde, Ministério da Saúde; 2004., providing for a series of interventions to strengthen the health system: (i) creation of the first Family Health Units in 2006 the Groupings of Health Centers in 2008, whose mission is to provide primary care to the population within a given geographic area; and (ii) the establishment of the Network of Comprehensive Continuous Care in 2006 to meet the needs of patients with chronic illnesses and in situations of dependency and whose current health status does not require hospitalization.

Implementation of the above-mentioned health policies and the country’s economic and social development contributed to the improvement of the Portuguese population’s health. The report by the WHO ⁷¹71. World Health Organization. Portugal health system performance assessment. Copenaghen: World Health Organization; 2010. that assessed the Portuguese health system’s performance emphasized significant improvements in the population’s health indicators, such as: (i) higher life expectancy; (ii) a fall in infant mortality (the highest in the European Union in 1980, but now one of the lowest); and (iii) a decrease in the mortality rate in individuals less than 65 years of age. Still, no similar progress was seen in other indicators like disability-free life expectancy and potential years of life lost ⁷¹71. World Health Organization. Portugal health system performance assessment. Copenaghen: World Health Organization; 2010..

Although the equity principle has guided Portugal’s health policies for the last 30 years, various studies ⁷²72. van Doorslaer E, Koolman X, Xander J, Andrew M. Explaining income-related inequalities in health care utilization in Europe. Health Econ 2004; 13:629-47.^,7373. Oliveira M, Bevan G. Measuring geographic inequities in the Portuguese health care system: an estimation of hospital care needs. Health Policy 2003; 66:277-93.^,7474. Mackenbach JP, Stirbu I, Roskam AJ, Schaap M, Menville G, Leinsalu M, et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med 2008; 358:2468-81.^,7575. Cabral MV, Silva PA. O estado da saúde em Portugal. Lisboa: Imprensas de Ciências Sociais; 2009.^,7676. Bago D'Uva TM. Equidade no sector da saúde em Portugal. In: Simões J, organizador. Trinta anos do serviço nacional de saúde. Coimbra: Almedina; 2010. p. 83-112.^,7777. Santana P. A saúde dos portugueses. In: Campos AC, Simões J, organizadores. 40 anos de abril na saúde. Coimbra: Almedina; 2014. p. 69-92. have detected inequalities favoring the higher socioeconomic strata in both access to and use of specialized services and health status. Mackenbach et al. ⁷⁴74. Mackenbach JP, Stirbu I, Roskam AJ, Schaap M, Menville G, Leinsalu M, et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med 2008; 358:2468-81., in a study in 22 European countries in the late 1990s and early 2000s, showed that in Portugal, health inequalities as perceived by the population (both men and women) are the highest among 19 European countries, especially when associated with level of education, and are equally significant, although not the highest, when associated with level of income. This relationship between health and socioeconomic variables was confirmed by other studies in the first decade of the 21st century ⁷³73. Oliveira M, Bevan G. Measuring geographic inequities in the Portuguese health care system: an estimation of hospital care needs. Health Policy 2003; 66:277-93.^,7878. Antunes R. The social space of health inequalities in Portugal. Soc Theory Health 2011; 9:393-409..

Inequality in access also depends on the concentration of health resources, especially in medium and high-complexity specialties, in the districts of Oporto, Coimbra, and Lisbon. Thus, regional inequalities in access to medical specialties and hospital care did not decrease from 2000 to 2009 ⁷³73. Oliveira M, Bevan G. Measuring geographic inequities in the Portuguese health care system: an estimation of hospital care needs. Health Policy 2003; 66:277-93.^,7676. Bago D'Uva TM. Equidade no sector da saúde em Portugal. In: Simões J, organizador. Trinta anos do serviço nacional de saúde. Coimbra: Almedina; 2010. p. 83-112.^,7979. Simões J, Augusto GF, Fronteira I, Hernández-Quevedo C. Portugal: health system review. Health Syst Transit 2017; 19:1-184..

Other studies, drawing on the results of national surveys, concentrated on the contribution of the various health subsystems to the production of inequalities. According to Bago D’Uva ⁷⁶76. Bago D'Uva TM. Equidade no sector da saúde em Portugal. In: Simões J, organizador. Trinta anos do serviço nacional de saúde. Coimbra: Almedina; 2010. p. 83-112., beneficiaries of private subsystems are more likely to use medical services and specialties or to use them more intensely when compared to beneficiaries of the SNS. Even today, the Portuguese health system is characterized by the simultaneous presence of the SNS and various subsystems of care that guarantee dual coverage for a portion of the population, some 20 to 25% 32,79, such as: (i) the public sector social protection subsystem for civil servants (ADSE), used by some 10% of the population, while mostly financed by taxpayers; (ii) the subsystem of the voluntary insurance sectors; and (iii) the private health insurance subsystem.

According to Barros et al. ³²32. Barros PP, Machado SR, Simões JA. Portugal. Health system review. Health Syst Transit 2011; 13:1-156., the fact that a large proportion of the population enjoys dual coverage through different typologies of health subsystems reveals clear inequalities in healthcare access.

The significant rise in user fees at all levels of care, implemented since January 2012 in the wake of the financial crisis, has further increased barriers to healthcare by the Portuguese population ⁸⁰80. Barros PP. Health policy reform in tough times: the case of Portugal. Health Policy 2012, 106:17-22..

Discussion

Studies in recent years have attempted to determine whether health inequalities vary between European countries with different welfare state systems. Some studies have found that the systems in Southern Europe have the most serious health inequalities, while the Scandinavian countries and the other Continental European countries tend to show smaller differences ²2. Eikemo TA, Huisman M, Bambra C, Kunst AE. Health inequalities according to educational level in different welfare regimes: a comparison of 23 European countries. Sociol Health Ill 2008; 3:565-82.. Most worrisome is that such inequalities have increased in all four countries of Southern Europe, although to different degrees, during the economic crisis starting in 2008 ⁸¹81. Matsaganis M, Leventi C. The distributional impact of austerity and the recession in southern Europe. South Eur Soc Polit 2014; 19:393-412.. Compared to other nations of the European Union, the four Southern European countries made large-scale cuts in public employment by failing to replace retirees, freezing new hiring, and even (in the case of Greece) firing tenured civil servants. In the four countries, the responses to the economic crisis (that is, the recipes imposed in the case of Greece and Portugal or strongly recommended by the Troika in the case of Spain and Italy) were similar, a sort of single recipe, as pointed out by Guillén & Pavolini ⁸²82. Guillén A, Pavolini E. Welfare states under strain in Southern Europe: overview of the special issue. Eur J Soc Secur 2015; 17:147-57.. The austerity measures in the health sector varied from freezes to severe cuts. The mean annual cutback was the most severe in Greece, followed by Portugal. In Italy, the decline in public spending in health was intensified in 2014. In Spain, the reduction was moderate until 2011, after which it also increased ²⁹29. Petmesidou M, Pavolini E, Guillén AM. South European healthcare systems under harsh austerity: a progress-regression mix? South Eur Soc Polit 2014; 19:331-52..

These data corroborate previous analyses identifying welfare states as an important factor the health of populations, as long as they consider health determinants ⁸²82. Guillén A, Pavolini E. Welfare states under strain in Southern Europe: overview of the special issue. Eur J Soc Secur 2015; 17:147-57..

Meanwhile, other researchers have correctly criticized the widespread use of Welfare State typologies for purportedly overlooking the diversity of social and health policies between countries with such regimes ⁴⁹49. Petmesidou M, Guillén A. 'Southern style' national health services. Recent reforms and trends in Spain and Greece. Soc Policy Adm 2008; 42:106-24.^,8282. Guillén A, Pavolini E. Welfare states under strain in Southern Europe: overview of the special issue. Eur J Soc Secur 2015; 17:147-57.. For example, epidemiological research has been questioned for having used the Esping-Andersen typology in a surprisingly acritical way ²¹21. Bambra C. Going beyond the three worlds of welfare capitalism: regime theory and public health research. J Epidemiol Community Health 2007; 61:1098-102.. Bramba ²¹21. Bambra C. Going beyond the three worlds of welfare capitalism: regime theory and public health research. J Epidemiol Community Health 2007; 61:1098-102. contends that a more critical approach is needed to classify welfare regimes, which are actually “ideal types”.

From this perspective, studies should prioritize a comparative analysis of more similar countries in terms of welfare state provision, identifying similar and different areas, exploring the potential contributions to comparing national diversities in health and health inequalities ²¹21. Bambra C. Going beyond the three worlds of welfare capitalism: regime theory and public health research. J Epidemiol Community Health 2007; 61:1098-102.. This would allow overcoming some simplistic generalizations by studies on welfare state systems and observing the diversity of paths taken by different countries which in some cases could lead to questioning the validity of the same Mediterranean model (i.e., Southern Europe) in relation to healthcare ⁸³83. Bambra C. Health inequalities and welfare state regimes: theoretical insights on a public health 'puzzle'. J Epidemiol Community Health 2011; 65:740-5..

In the case of the social protection regimes in Southern European countries, our analysis has highlighted common characteristics and trends in their health systems and the inequalities, as well as some significant differences between the four countries.

Although to different degrees and in different dimensions, the common characteristics include inequalities in access to and use of services, in morbidity and mortality associated with social and economic variables such as work status, housing, income, schooling, and social capital ⁶6. European Commission. Report on health inequalities in the European Union. Commission staff working document. Brussells: European Commission; 2013.^,8484. Ferrera M, editor. Welfare state reform in southern Europe: fighting poverty and social exclusion in Italy, Spain, Portugal and Greece. London: Routledge; 2005..

Another key aspect is the steady increase in out-of-pocket spending in health as a percentage of total health spending in all four countries, markedly in Greece and Portugal: 24.5% in Italy, 30.1% in Spain, 34% in Portugal, and 39.4% in Greece ⁸⁵85. Organisation for Economic Co-operation and Development. Society at a glance 2014: OECD social indicators. Paris: OECD Publishing; 2016., despite acknowledgement of the right to health and universal and free access for all citizens, as proclaimed by the respective national health services. Such data reveal growing privatization of health services. As the state reduces its global financial responsibility for healthcare, a substantial share of the cost is shifted to families and individuals through the proliferation of private health plans, with rising out-of-pocket payments by families, resulting in more unequal national health systems. Low and middle-income groups have been disproportionately affected by such conditions, significantly limiting access to healthcare ²⁹29. Petmesidou M, Pavolini E, Guillén AM. South European healthcare systems under harsh austerity: a progress-regression mix? South Eur Soc Polit 2014; 19:331-52..

Geographic inequality in health is another critical issue, observed in all four Southern European countries. Differences exist between: (i) the economically more developed regions of the north of Spain as compared to the south and west; (ii) the underfinanced regional health systems of the Peloponnesus, Central Greece, and the Aegean and Ionian islands when compared to Greater Athens and Macedonia; (iii) the regions of south and central Italy and the wealthier regions of the north; and (iv) the districts of Oporto, Coimbra, and Lisbon and the other districts in the countryside of Portugal.

Another interesting issue in the four countries, although with different levels of acceleration and scope, is decentralization of the national health systems. The cases of Italy and Spain are paradoxical - both with a higher degree of regional decentralization in the financing, management, and provision of health services - while evidence shows that decentralization has not helped reduce the historical difference in performance between the various regional health systems. On the contrary, such inequalities appear to have increased in recent years ³⁸38. Soria B. Informe Bernat Soria. Madrid: Abbott Laboratories; 2011.^,8686. Pavolini E, Vicarelli G. Is decentralization good for your health? Transformations in the Italian NHS. Curr Sociol 2012; 64:472-88..

The article has identified potential inequalities induced by the reform processes at the national, regional, and local levels. These feature the institutional arrangements introduced in the health systems and the new relations between the public and private sectors in services provision. For example, the experiences introduced in Italy (treatment of private inpatients in public hospitals, or intramoenia) and in Greece (afternoon and evening rules allowing physicians, hospital employees, and public health centers to exercise liberal private practice in the same facilities after their normal work shifts). The justification cited for this strategy is to facilitate access to specialized services and bolster the public sector’s competitiveness in relation to the private sector, by increasing its efficiency. Meanwhile, the result is a kind of professional practice that generates inequalities by creating two categories of citizens within the same public services: (i) those that opt for public services and are included on a long waiting list and (ii) those that opt for a service with copayment whereby they receive treatment within just a few days.

An example of how health systems produce inequalities is the rising proportion of users’ health expenses covered by copayments and user fees. The procedure is already consolidated in the countries of Southern Europe (especially Greece, Italy, and Portugal), introducing financial hurdles to access and further aggravating inequalities in public healthcare ⁴⁷47. Navarro V. The social crisis of the Eurozone: the case of Spain. Int J Health Serv 2013; 43:189-92.^,8787. Cavicchi I. La controriforma della sanità italiana. SaluteInternazionale.info 2015; 23 mar. http://www.saluteinternazionale.info/2015/03/la-controriforma-della-sanita-italiana/ (acessado em 06/Set/2016).
http://www.saluteinternazionale.info/201... . In Spain, the only fee for use of health services is for pharmaceutical products. The introduction or increase in user fees for primary care and/or appointments with specialists can worsen the health outcomes and fuel the increase in the use of intensive services and resources such as emergency care ¹¹11. Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu S, Stuckler D, et al. Financial crisis, austerity, and health in Europe. Lancet 2013; 381:1323-31.^,8888. Serapioni M. Taxas moderadoras. In: Santos BS, organizador. Dicionário das crises e das alternativas. Coimbra: Almedina; 2012. p. 200-1..

Finally, the negative repercussions of the financial crisis and austerity policies have particularly affected the countries of Southern Europe. One issue that has received relatively little attention is the impact of these policies on social inequalities in health. Budget cuts and on-going privatization plans in hospitals and primary care centers are leading to steady deterioration in the quality of services, while increasing waiting times, besides increasing the requirement of copayments for medicines and other health services. According to a report by the Organization for Economic Cooperation and Development (OECD) ⁸⁹89. Organisation for Economic Co-operation and Development. Crisis squeezes income and puts pressure on inequality and poverty: results from the OECD Income Distribution Database. Paris: Organisation for Economic Co-operation and Development; 2013., the increase in inequality has been particularly evident in countries that have implemented deep budget cuts, like Spain, Greece, Italy, Ireland, and Portugal. The negative consequences of the crisis tend to concentrate in people that lose their jobs and the population’s most vulnerable groups. Higher rates of precarious employment and lower per capita health spending have a negative effect on people’s mental health ¹²12. Ruiz-Pérez I, Bermudez-Tamayo C, Rodríguez-Barranco M. Socio-economic factors linked with mental health during the recession: a multilevel analysis. Int J Equity Health 2017; 16:45.. The decrease in healthcare access is particularly evident in Greece and to a lesser extent in Italy, Spain, and Portugal, but in all four countries the barriers to access are higher in the elderly over 75 years of age ²⁹29. Petmesidou M, Pavolini E, Guillén AM. South European healthcare systems under harsh austerity: a progress-regression mix? South Eur Soc Polit 2014; 19:331-52..

Conclusion

The article aimed to describe the paths taken by health systems reforms in Spain, Greece, Italy, and Portugal and analyze the main forms of health inequalities identified in these countries before and during the economic crisis of 2008, based on a systematic literature review. In the context of the European welfare state, the article provides an overall profile of the national health services in the four countries, established in the 1970s and 1980s, but still displaying some differences in their criteria for access, equity, and financing. Economic crisis and austerity policies increased the dissatisfaction with healthcare provision in all the countries, particularly Greece and Portugal. The crisis sparked a drastic cutback in public spending in Greece, a significant decline in Portugal, a perceptible contraction in Spain, and a moderate reduction in Italy.

Such developments have obviously increased the inequality in health due to individuals’ differential ability to take out private insurance and complementary health plans on the market. In the four countries, the social gradient (particularly in education, income, and work status) is the principal determinant factor in health inequalities. Another critical issue in the four countries involves geographic inequalities in access to health services as the result of different levels of economic development in the various regions.

One question we sought to examine, and that has received little attention in the international literature, involves the potential inequalities generated by health systems reforms and the austerity policies still under way.

The recent debate in the international literature has focused on the relationship between different welfare state regimes and health inequalities. The use of welfare state typologies as a determinant of health and health inequalities has been criticized for overshadowing important differences in economic and social policies between the welfare states.

Finally, the findings presented here should be viewed as preliminary results of a research in progress. The characteristics and specificities of the reforms adopted by the countries of Southern Europe during this period of financial turmoil call for further studies and new analytical perspectives. Future studies based on systematic literature reviews should allow reaching even more solid conclusions on the impact of such austerity policies on health systems and social inequalities in health.

References

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