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Economic crisis and health. the role of health care professionals

Venetia Notara1*, Konstantinos Koulouridis2, Aristidis Violatzis3 and Elissabet Vagka1
  1. Lecturer, RHV, MSc, Health Visiting Department, Faculty of Health and Caring Professions, Technological Educational Institute (ATEI) of Athens, Greece
  2. Clinical Nurse, Mental Health, MSc, Psychiatric Hospital of Athens (Dafni), Greece
  3. Clinical Psychologist, Psychotherapist, MSc. Special Secretary for Violence National Network of Greece
Corresponding Author: Notara Venetia Thivon Av. 274 Telephone: + 30 2105385756, Fax number: + 30 2105385758, E-mail: [email protected]
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Background: The economic downturn unfolded in the recent years is expected to produce adverse social and health effects. Several studies support the fact that such financial depressions have a direct impact on the overall health, on the public spending directed to the health care system, on the quality of the provided services and on the restructure of the roles and functions of the health care personnel.Aims: The purpose of the present study was to review data on the factors that economic crisis affect population’s health and health care professional’s role. The objectives were to investigate how economic changes can affect early mortality and morbidity rates, suicide tendencies, mental disorders and to highlight the emerging problems that health care professionals are faced with, in both the workplace environment and the educational field. Methodology: A literature review of national and international studies was performed in databases of PubMed and Scopus using keywords such as economic crisis, health implications, public health, unemployment, mental health, healthcare (nursing) education. Results: A large number of studies indicate a strong correlation between unemployment or low income level and increased mortality rates, suicide tendencies, mental disorders, changing eating habits and over?consumption of tobacco and alcohol.Conclusions: Economic crises can be addressed as an opportunity for health reform policies, for minimizing the inequalities in health services access, for providing more cost?effective and efficient services and for identifying actions that can help to mitigate the negative impact of financial shortages. Emphasis should be given in the improvement of the primary health care provision, in the better performance of health promotion programs, in minimizing health inequalities and diminish the rates of hospitalisation.

Key words

Economic crisis, health implications, public health, unemployment


Over the past years almost all countries are suffering from the global economic recession which is characterized by a rise in unemployment or reductions in wages leading to a lower income. Loosing a job can have more harsh effects on mental health than other life changes.1
According to the WHO report, in periods with serious economic downturns the most affected people are those who belong to the low socio?economic groups, the risk of psychiatric disorders and suicides tend to increase and public expenditure for health and welfare services are diminished in order to allocate investments to other areas.2 Those cuts may lead to a restructureof the roles and functions of the health care personnel, resulting in a deterioration of the quality of services provided.3
Thus, the crisis is expected to increase the burden of illness and deepen the social inequalities which in their turn will lead to poverty and social deprivation.4,5


A Pubmed and Scopus database search was performed in order to identify studies of economic crisis and its effects on public health and health care professionals. Keywords such as economic crisis, health implications, public health, unemployment, mental health, healthcare (nursing) education were selected.
Studies addressing the relationship between economic shortages, health problems, public spending, use of public health care services, social problems were used while, mainly, a ten year time frame was set in order to include the most recent studies.


A large number of studies indicate a strong correlation between unemployment or low income level and increased mortality rates, suicide tendencies, mental disorders, changing eating habits and over?consumption of tobacco and alcohol. The aforementioned effects on overall health increase the demand for public health care services. Additionally, health spending cuts have a direct impact on health care professionals, who are invited to provide high level of care with the minimal resources (supplies). Consequently, economic constraints are likely to have a negative effect on the quality assurance in higher education (i.e. lack of staff, equipment and facilities).

Unemployment and adverse health effects

The downturns in economic activity increase the rates of unemployment6 which consequently affect the mental and physical health. Several studies indicated that people who lost their job suffered from symptoms of somatization, depression, anxiety and they were more likely to visit their physicians and take more medication. Historically, the loss of job and income are associated with economic crisis and have a deleterious effect on people’s daily lives but if individuals are encouraged to participate in social events/networks it can facilitate coping with unemployment.7?9 Job insecurity is also associated with drug addiction, increased rates of suicide and heart disease, mental disorders with the most vulnerable groups those who belong to the low socio?economic classes. Actually it is described that a long term job insecurity acts as a chronic stressor which increases sickness, absence and utilization of health care services. 10,11 According to the Organisation for Economic Co?operation and Development OECD forum, supportive programmes for education and training can help displaced workers find new job opportunities and thus prevent some adverse health effects and alongside promote skilled personnel to support innovative market prospects.12

Economic crisis and use of public health care services

There is a widespread agreement that, in stressful economic and social circumstances the demand on public health services is increased for the reason that patients turn from the private to public sector services since the cost of care is lower.2 However, the high utilization of the health care system doesn’t always mean the presence of organic pathology as, in some cases, psychological disorders can be masked by physical complaints.13 Patients perceive themselves as sick and physically disabled.14
It also seems that, health care consumption depends on the household income as it is interpreted in the results from a study conducted in Seoul displaying that the high income groups haven’t changed their frequency of visits in medical services whereas the lower income groups have minimized mainly the drug expenditure and secondly the expenditure on medical services. Losses of income don’t allow for “unnecessary” expenses.15 The prementioned results come in accordance with the study of Gottret et al.,16 concluding that households who experience reductions in income and employment reduce as well the use of health care services. Apparently, the health care utilization is complicated and difficult to be predicted since population and income features play a major role. Nevertheless, focused efforts in ensuring major parameters of quality in healthcare such as the equal access to essential health commodities, the population needs assessment and the short?term oriented interventions, can be proved to be more effective.

Economic crisis and mortality rates

A study conducted in 26 European Union countries concluded that economic downturn has many attributes that can occur simultaneously including unemployment, premature deaths from intentional violence, suicides, homicides and alcohol abuse.17 In a relevant review study, which was conducted in Greece, authors stated that economic decline in middle or low income countries is associated with increase in mortality in general, as well as mortality from the most common diseases, while mortality from transport accidents was decreased probably due to the limitation of traveling.18
The Asian economic recession, which caused a sudden increase in unemployment, has also led to an increase in suicide mortality rates, reflecting a significant harmful mental health effect associated with the recession.19,20 As described by Economou et al.,21 in a workshop that was held in 13 European Union Countries, there is a strong relationship between unemployment and an increase in cardiovascular mortality. One possible explanation is that acute stress and depression have been associated with elevated levels of cytokines and leukocyte which lead to elevated blood pressure via catecholamines.22
Although there is an expanding literature that documents the relationship between economic fluctuations and health, controversies do exist about the mechanisms that induce the pre?mentioned relationship. Other recent research indicates that health deteriorates when the economy temporarily improves since it is associated with increased smoking and obesity, reduced physical activity and unhealthy diet.23 Gerdtham & Ruhm24 have stated that countries with weak social insurance protections can foster fluctuations in mortality rates compared to those with more extensive programs. Neumayer25 has found that the total mortality rates are lowered in recessions.

Economic crisis and vulnerable groups

Poor social groups are those who are mainly affected by the repercussions of the crisis, since socioeconomic factors play a major role in the psychological health level of the population. Income inequalities, occupational status and productivity capacity are important indicators for the sense of well?being and the overall health of the individuals.26,27 It is worth mentioning that high?income countries, compared to those with low?income, have low fertility and mortality rates and increased life expectancies while the disease map to some extent is totally different from the low?income countries which are faced with high mortality rates from infectious diseases and maternal and childhood mal?conditions.28
The major cause of inequality and relative poverty is unemployment. Income equality seems to improve social cohesion and reduce the social divisions. A rise in unemployment which leads to lower income can harm nutritional intake and quality of life.29
Social and public health policies that can cover the most important health determinants by reducing unemployment, minimizing income and wealth inequality, showed evidence of improved population health as presented in comparative studies of policies on health inequalities form 8 different European countries.30

Economic crisis and implications for health professionals

Governments’ concern in periods of economic downturns is to take measures for reducing public sector expenses, including public health care services, which have to reduce their operating and labour costs so as to control their expenditures. Meanwhile, several studies have documented an association between lower nurse staffing levels and higher rates of some adverse patient outcomes addressing the safety and the quality of health care provision.31?33 Similarly, another study found that health care personnel shortages will make health professionals scarce and tasks more strenuous.34 Burnout and job dissatisfaction are more likely to be revealed in hospitals with high patient?to?nurse ratios35 and that comes in accordance with the results of Rafferty et al.,36 describing that the lowest patient?to?nurse ratios the better outcomes while the nurses in the high patient?to?nurse ratios hospitals were approximately twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care on their wards and hospitals. According to the WHO Report,37 income is the most important motivation for health workers’ migration followed by job dissatisfaction, career opportunities and political instability.
Complementing those studies are a number of other studies addressing the negative impacts of the economic crisis on nursing education38?40 which requires teaching staff, facilities, equipment and supplies so as to meet high quality standards.
On the other hand, health care personnel need to be alert and respond to the changes in the health care landscape so as to contribute and influence for most cost effective reform processes.41,42,38 Special attention should be paid to strengthening areas such as primary health care, public health and health promotion in the direction of minimizing the demand of hospital services.34 The pre?mentioned study comes in accordance with the priorities referred to the Primary Health Care Reform in Australia43 which “sets the policy direction to better connect hospitals, primary and community care to meet patient needs, improve continuity of care and reduce demand on hospitals”.
As it is described in the study of Lionis et al.,44 the strengthening of the primary care sector can result in a better quality of care provided, rationalise the health care expenditure, reduce unplanned hospital admissions and increase user’s satisfaction. The WHO Report45 stated the need to enhance the primary care sector, due to health transition and changing social attitudes, in co?ordination with the other two constituents of the health system?secondary and tertiary care? since all of them constitute the system as an integrated entity.


Extended research data reveal that people’s health status is definitely affected by the economic crisis and consequently the healthcare sector will be charged to meet efficiently the increasing needs. At the same time demographic changes (lower fertility, aging) and disease burdens shift (non? communicable diseases and injuries) will have profound effects on the quantity and type of healthcare services needed. Crisis may also have an impact on social inequalities in health, inequitable access and low quality of healthcare through a deterioration of social determinants of health (loss of job?income, lack of health insurance, lack of information, direct financial costs of care, etc). Resources restrictions on healthcare personnel may affect the safety and quality of health care provision.
Nevertheless, these challenges can be considered as an opportunity and a motivation to improve efficiency by developing health care policies to ameliorate the performance of health care systems. The goal of such reformations is to remove policies that have been proved to be expensive, inefficient, unsafe and unequal.
There is widespread acceptance that health reforms should emphasize on the field of prevention and early intervention. Flexible systems, different patterns of allocation, ways of working and tailored health care services to the community needs, could be some of the steps to cope with the epidemiological transitions such as aging, non communicable diseases, accidents and injuries, low fertility, etc. Primary healthcare is considered the key component to attain this target as was adopted, years ago, by the Declaration of Alma?Ata to achieve the goal of “Health For All”.
Probably is too early to have definite estimates but certainly a serious and well planned reorganization of the health care institutions can be proved extremely effective to improve population health status in the future and tackle health problems in the early stages.


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