Crisis, Austerity and Health Inequalities in Southern European Countries

Centro de Estudos Sociais | Publicação semestral | n.31 31 Crisis, Austerity and Health Inequalities in Southern European Countries

PROPRIEDADE E EDIÇÃO CENTRO DE ESTUDOS SOCIAIS UNIVERSIDADE DE COIMBRA www.ces.uc.pt

COLÉGIO DE S. JERÓNIMO APARTADO 3087 3000-995 COIMBRA PORTUGAL URL: http://journals.openedition.org/eces/ E-MAIL: [email protected] TEL: +351 239 855 573 FAX: +351 239 855 589

CONSELHO DE REDAÇÃO DA E-CADERNOS CES MARIA JOSÉ CANELO (Diretora), CRISTIANO GIANOLLA, FILIPE SANTOS, MAURO SERAPIONI, PABLO PÉREZ NAVARRO, PATRÍCIA SILVA, PAULO PEIXOTO, TERESA MANECA LIMA, VÍTOR NEVES

AUTORES/AS MAURO SERAPIONI, PEDRO HESPANHA, MARIA PETMESIDOU, JUAN ANTONIO CÓRDOBA-DOÑA, ANTONIO ESCOLAR-PUJOLAR, ELENA CACHÓN GONZÁLEZ, RAÚL PAYÁ CASTIBLANQUE, STEFANO NERI, ROSSELLA DE FALCO, TÂNIA REGINA KRÜGER, ROSANA MIRALES

COORDENADORA DE EDIÇÃO ANA SOFIA VELOSO

ASSISTENTE DE EDIÇÃO ALINA TIMÓTEO

CAPA ANDRÉ QUEDA

PERIODICIDADE SEMESTRAL

VERSÃO ELETRÓNICA ISSN 1647-0737

CRISIS, AUSTERITY AND HEALTH INEQUALITIES IN SOUTHERN EUROPEAN COUNTRIES

EDITION Mauro Serapioni and Pedro Hespanha

CENTRO DE ESTUDOS SOCIAIS 2019

Index

Mauro Serapioni, Pedro Hespanha – Crisis and Austerity in Southern Europe: Impact on Economies and Societies ...... 4

Maria Petmesidou – Challenges to Healthcare Reform in Crisis-Hit Greece ...... 19

Pedro Hespanha – The Impact of Austerity on the Portuguese National Health Service, Citizens’ Well-Being, and Health Inequalities ...... 43

Juan Antonio Córdoba-Doña, Antonio Escolar-Pujolar – The Lasting Effects of a “Relentless Crisis”: The Great Recession and Health Inequalities in Spain ...... 68

Elena Cachón González – Crisis, salud y calidad de vida. Algunas evidencias en España y Portugal ...... 93

Raúl Payá Castiblanque – Contexto económico y determinantes sociales de la accidentabilidad laboral en el sur de Europa. Los casos portugués y español ...... 116

Stefano Neri – The Italian National Health Service after the Economic Crisis: From Decentralization to Differentiated Federalism ...... 147

Rossella De Falco – Access to Healthcare and the Global Financial Crisis in Italy: A Human Rights Perspective...... 170

@cetera

Tânia Regina Krüger – Sistema Único de Saúde: redução das funções públicas e ampliação para o mercado ...... 195

Rosana Mirales – Debate sobre os fundamentos do conservadorismo ...... 212 e-cadernos CES, 31, 2019: 04-18

MAURO SERAPIONI, PEDRO HESPANHA

CRISIS AND AUSTERITY IN SOUTHERN EUROPE: IMPACT ON ECONOMIES AND SOCIETIES

Abstract: This article discusses the economic and social impact of the 2008 crisis and its related austerity policy on South European countries (SEC). Damages caused by these policies includes the decrease in GDP, the increase in unemployment and precariousness, especially amongst the younger population, and the worsening of social services. SEC health systems have also been seriously affected by the crisis, with a particular impact on the most vulnerable social groups, as a result of the decrease in public health expenditure. The increase in health inequalities is another side effect of the structural adjustment programs. Keywords: crisis, health inequalities, health systems, South European countries.

CRISE E AUSTERIDADE NO SUL DA EUROPA: IMPACTO NAS ECONOMIAS E SOCIEDADES

Resumo: Este artigo analisa o impacto social e económico da crise de 2008 e das políticas de austeridade dela derivadas nos países do Sul da Europa (PSE). Os danos causados pelas políticas de austeridade 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 de saúde dos PSE também foram seriamente afetados pela crise, atingindo particularmente os grupos sociais mais vulneráveis, como resultado da redução da despesa pública em saúde. O aumento das desigualdades na saúde é outro efeito colateral dos programas de ajuste estrutural. Palavras-chave: crise, desigualdades de saúde, países do Sul da Europa, sistemas de saúde.

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 the diversity of existing welfare state models and of the functions of social policy in order to define the relevant options for decision-making. More recently, Esping-Andersen (1990), in his research on the political economy of the welfare state in advanced capitalist societies, empirically confirmed the validity of Titmuss’s typology for a broad set of the

4 Mauro Serapioni, Pedro Hespanha 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 typology as the three worlds of welfare capitalism, this author associates to a certain extent a geographical 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. The impact of this typology on subsequent studies has been enormous, some of them claiming that other groups of countries do not fit properly in Esping-Andersen’s trilogy and that they therefore represent a flagrant gap to be filled. This is the case of the Southern 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 Mediterranean model (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 the outstanding attributes of the welfare state in these countries, particularly suitable for health systems, is their universalist approach. In fact, all of these four countries, in the final phase of the expansion of their welfare states between the 1970s and 1980s created their own national health services (NHS) with universal access inspired in the Beveridgean model established in the United Kingdom in 1948. Among the common aspects of these Southern European NHS the following should be mentioned: (i) inconsistency between the universal promises and the effective response given to citizens’ needs due to limitations in the process of implementation of national health services, in particular financial constraints (Giarelli, 2006); ii) difficulties in the management of the public system that led governments to introduce reforms aiming to improve efficiency, namely by following the rules of new public management (Cabiedes and Guillén, 2001); iii) the importance of non-professional human resources, such as family and primary care networks to compensate for the NHS’s deficiencies (Santos, 1987; León and Migliavacca, 2013); iv) lack of participation by the users’ representatives in decisions about health policy and in the organization of health services (Matos and Serapioni, 2017). Despite these limitations, the four countries have significantly improved health indicators thanks to the social and economic development of the last decades and the continuous improvement of health care. However, these indicators, which are generally very positive, conceal situations of great inequality both in the distribution of economic 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 what happened during

5 Crisis and Austerity in Southern Europe: Impact on Economies and Societies the recent financial crisis of 2008 in these four Southern European countries, which soon became a systemic – economic, social, and political – crisis (Laparra and Pérez Eransus, 2012). Due to inequalities between Eurozone economies, crises may affect only some of them and spare the others, with the Economic and Monetary Union (EMU) common rule not applying in such cases. On the contrary, EMU contributes both to the reinforcement of inequalities, i) when promoting the specialization of economies in productions in which they have higher relative efficiency and ii) when removing from Member States the possibility of using important economic and monetary instruments, such as the reduction of interest rates, currency devaluation, or public expenditure increase. What seems to be particularly distinctive in this crisis is that, thanks to the existence of a monetary system that imposes strict limitations on the use of traditional crisis management tools, the room for government maneuver has been greatly reduced in so far as the supervision of supranational institutions is concerned. In turn, for those under financial assistance the imposition of adjustment programs eventually came to control their sovereignty. The creditors’ own preferred solution – austerity rule – has been adopted against the risk of worsening the financial crisis even by those Member States which did not have to resort to financial assistance, as in the case of Italy. Austerity rule has contours that are not well defined and may have quite different interpretations. In a nutshell, it refers to a set of economic and social policies by which governments aim to halt or reduce public expenditure. We would also highlight the fact that these options allow for the “modification of the State’s redistributive policy and of the expenditure related to the functioning of the economy and social reproduction” (Ferreira, 2014: 117).1 Damages caused by austerity policies to the economies and societies of countries which had to adopt them showed in different forms. From early on, decrease in the GDP or even deep recessions (Table 1) with serious future implications occurred, not only due to investment halt and sovereign debt increase (Table 2), but mainly as a result of social consequences: job destruction and increase in unemployment (Table 3); precariousness, especially in younger segments of the economically active population; large emigration flows of qualified workers; and the worsening of poverty, social exclusion (Table 4) and income inequalities (Table 5).

1 All the translations have been made by the authors.

6 Mauro Serapioni, Pedro Hespanha

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

Source: Eurostat (2018).

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

Eurozone 7.6 9.6 10.2 10.2 11.4 12.0 11.6

Source: Eurostat (2018).

7 Crisis and Austerity in Southern Europe: Impact on Economies and Societies

TABLE 4 – At-Risk-of-Poverty or Social Exclusion* Rate (%) (2008-2014) Greece, Portugal, Spain, Italy and 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 (the top quintile) to that received by the 20% of the population with the lowest income (the bottom quintile). Source: Eurostat (2018).

The comparative analysis of austerity policies effects in four countries severely affected by the crisis (Greece, Portugal, Spain, and Italy) shows that, although the range of available political instruments is limited and not very diversified, the way in which they are combined and implemented is crucial to explain the different effects austerity policies had in each country. Table 6 summarizes the measures adopted by these four countries. It should be noted that only two of them (Greece and Portugal) were under a very heavy financial assistance program, contrary to what happened in Spain where the intervention was not in the form of a sovereign debt relief but of a program of assistance for the recapitalization and restructuring of the banking sector. The same applies to Italy, where the possibility

8 Mauro Serapioni, Pedro Hespanha of requesting an emergency loan in order to overcome the sovereign debt crisis was seen as the “point of no return” for the stability of the euro area in its entirety. As the Eurozone’s third largest economy, Italy was considered “too big 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 individual Increase in Introduction of Increase in individual income tax rates, individual income an additional income tax rates; partially compensated tax rates; income tax rate Reintroduction of a by decreasing tax rates for top earners. Introduction of an housing property tax. for lower bands; additional tax rate Changes in the fiscal for top earners; benefits and bonuses Reduction of fiscal Widening of the benefits. contributory basis.

Cuts in public pensions; Freezing of nearly Freezing of Reform of the all social insurance public pensions. pension system, Introduction of a one-off benefits and raising the retirement additional tax on pensions. age for women and incomes and a special men. tax on pensions. Deep cuts in social spending at national and local level

Increase on VAT taxes. Increase on VAT Increase on Increase on VAT taxes. VAT taxes. taxes.

Cuts in public sector Cuts in public Cuts in public wages. sector wages. sector wages.

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

Without going into further detail, the differences regarding the implementation of austerity rule are evident, as well as the similarities between the policy instruments used. With regard to the structural adjustment programs agreed with the Troika in the health sector, it is worth recalling the factors triggering the financial crisis and the problems that led three Southern European countries (Greece, Portugal and Spain) to be submitted to a readjustment programme. 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 the Eurozone, determined a fast growth of bank credit demand (especially for expenses with durable consumer goods, including housing) favored by low interest rates. As a consequence, foreign commerce registered an increasing negative balance whereas

9 Crisis and Austerity in Southern Europe: Impact on Economies and Societies competitiveness levels deteriorated, at the same time that public administration expenditure expanded; this resulted in the aggravation of the annual deficit in public accounts, which reached the peak of 14% of the GDP in 2008, and a sovereign debt of 115% of the GDP in 2009 (European Commission, 2010). This was the earliest case of external intervention, which occurred in May 2010; it is also accounts for the longest ongoing intervention, with a second rescue program starting in June 2012 in the form of a partial debt relief, and a third program starting in August 2015 (European Commission, 2012, 2015) In Portugal there were similar causes: accumulation of high external debts in previous years by the State as well as by families or firms. The growing demand for external financing for public debt and banking investment originated a strong interest rate increase in the financial markets along with a rating degradation of the Portuguese sovereign debt and bank solvency. The adjustment program started in May 2011 and lasted until mid-2015 (European Commission, 2014). There are two aspects to be highlighted in the Portuguese case for the assessment of the reforms: firstly, since 2009, before entering the program, the government had implemented a set of measures to combat the crisis – Stability and Growth Programs I, II and III – basically consisting of public expenditure reduction; secondly, the right-wing coalition government, which had the responsibility for implementing the adjustment program agreed with the Troika used the opportunity to impose its own agenda, clearly of a neoliberal character, moving further than the settled goals by means of reinforced austerity measures (Table 7).

TABLE 7 – The Adjustment Programs in Greece, Portugal and Spain

Greece Portugal Spain

2010 (May 2nd): First economic 2011 (May 17th): The 2012 (July 23rd): The adjustment program in the amount economic adjustment economic adjustment of €80 billion euros to be released program in the amount program in the amount of during be period from May 2010 to of €78 billion euros, €100 billion euros for June 2013. during the period of recapitalization and 2011 to mid-2014, to re-structuring of the 2012: Second economic adjustment re-establish access to Spanish financial sector. program in the additional amount of financial markets, €130 billion euros for the years enabling the recovery 2012-2014; later postponed until of the economy to the end of June 2015. sustainable growth 2015 (August 19th): Third economic and to safeguard adjustment program in the amount financial stability in of €86 billion euros in financial Portugal, in the assistance from 2015 through Eurozone and in the 2018. EU.

Source: Hespanha, 2017.

10 Mauro Serapioni, Pedro Hespanha 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 and restructuring of the banking system. The decapitalization of banks followed the burst of a construction industry bubble in 2008 and the deep involvement of banks in financing that sector. Reforms undertaken by the Spanish government were insufficient to reduce the pressure of financial markets and the stress levels of banks; this forced the Spanish government to request financial assistance in 2012 (European Commission, 2012). The Memorandums of Understanding (MoUs) subscribed by the governments of countries subjected to financial aid comprise a set of measures specifically directed at the health sector, along with other transversal measures aiming to reduce public expenditure that equally affected this sector. Our analysis will focus on these measures. The main remark to be made when comparing the general objectives of the MoUs is that Troika’s ‘recipes’ did not differ much and concentrated on a limited amount of objectives, somehow hindering the adaptation to the specificities of each country in economic, social and political terms, and making it necessary for governments and the Troika 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 accept the alternatives offered by the national governments for the attainment of the same targets; b) each of these three countries received a different treatment regarding the margin of flexibility consented by the Troika. For example, in the case of Spain there was no such detailed program concerning the measures to be implemented in order to reach the goals (European Commission, 2012). Therefore, the main axes of the health sector reform the three countries had in common concerns control of public expenditure and improvement of the services efficiency and effectiveness, including the promotion of a more rational use of resources and services, such as, for example, the reduction of the fragmentation of services or the dispersion of their tutelage (Table 8). 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 policies was significant during the sovereign debt crisis between 2011 and 2012. In order to have the support of the European Central Bank, Italy engaged in a series of structural reforms, accepting the ‘implicit conditionality’, an instrument used by the European Union during the Eurozone crisis and “based on an implicit understanding of the stakes and 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 main issues that could be submitted to reforms, other sectors were also affected. Among the austerity policies

11 Crisis and Austerity in Southern Europe: Impact on Economies and Societies implemented in the Italian health sector, it is worth mentioning the following (Dirindin, 2011; Ferré et al., 2014; Maciocco, 2015): • Increased co-payment for medicines, out-patient care and non-necessary emergency admissions; • 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 in pharmacy 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: General objectives: General objectives: - Control public expenditure - Improve efficiency and - Implement reforms in the and increase efficiency, cost- cost-effectiveness; public sector to improve the effectiveness and equity of efficiency and the quality of - Stimulate a more rational the system; public expenditure in all of use of health services; governmental levels; - Stimulate savings by - Control public expenditure means of a more rational use - Integrate the funds in order in health. of resources; to simplify a highly segmented system; - Concentrate all institutions and policies related to health - Concentrate measures under the responsibility of the related to health under one Ministry of Health. ministerial coordination.

Source: Hespanha, 2017.

The average annual rate of contraction of public health expenditure in the SEC between 2009 and 2017 has been significant. According to the OECD it was more pronounced in Greece, followed by Spain, Italy, and Portugal (Table 9). In the same period, the majority of the countries of other European macro-regions have maintained the normal rate of growth in public health expenditure (Germany, France and Sweden), or have registered smaller decreases (Czech Republic, Poland and Hungary), with the exception of Great Britain and Ireland, which suffered a substantial reduction (5.1% and 4.5% respectively) (Serapioni, 2018).

12 Mauro Serapioni, Pedro Hespanha

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.

Several studies have highlighted the effects of the crisis on health systems in Southern European countries, particularly on the most vulnerable social groups, leading, for instance to an increase in mental disorders as well as in suicides (De Vogli, 2014). These effects 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 austerity policies have been imposed or vigorously recommended (Petmesidou et al., 2014), and involved “blind cuts and disqualification of services” (Hespanha, 2017: 95). The increase in health inequalities, both social and geographical, is also one of the side effects of the structural adjustment policies applied in the SEC (Escolar-Pujolar et al., 2014; Guillén et al., 2016). This thematic issue of e-cadernos CES gathers contributions from scholars and researchers who have dealt with the relationship between crisis, austerity policies and

NHS reforms on the one hand, and the growth of health inequalities on the other. In the first article, Maria Petmesidou presents the slow and tortuous process for reforming the health system in Greece from the early 1980s until the outbreak of the crisis in 2008. In this context, the author analyses how, under the pressure of the sovereign debt crisis, the shift in institutional and power relations has forced political actors to recognize the functional limits of the health system and to accept the implementation of a set of policy measures and regulatory instruments that formed the basis of reform. In the second part, the article illustrates the main reforms defined in the Troika rescue package and then examines the impact of such measures. Among the expected results of the reform, the author emphasizes the unification and rationalization of health insurance, in order to oppose the fragmentation of the health system and the inequalities of coverage and access. At the same time, however, the author notes that the contraction of financial and human resources has dramatically reduced the scope, quantity and quality of the

13 Crisis and Austerity in Southern Europe: Impact on Economies and Societies services provided, as well as increasingly unmet medical needs, especially among the most vulnerable social groups, thus deepening inequalities in terms of accessibility. The case of Portugal is analysed by Pedro Hespanha by debating the guidelines of the main health reforms carried out or planned in Portugal to ensure the financial sustainability of the health system since 2010; Hespanha concludes from distinct evidence that, although most of the health reforms would be useful and necessary, those implemented produced negative and somehow unforeseen consequences due to their 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 affects citizens differs according to their social condition and the ways in which they deal with the situation. Hence, health inequalities were kept consistently higher than those observed in other European countries in the last decade and continue to be closely associated with socioeconomic factors. The article by Juan Antonio Córdoba-Doña and Antonio Escolar-Pujolar reviews the main findings on the impacts of the crisis on health inequalities in Spain. The authors first 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 public spending on health as well as the privatisation and dismantling of the SNHS, focusing especially on citizens' responses to austerity measures. The widespread discontent and the civic indignation against neoliberal austerity policies are considered by the authors as the most remarkable episodes of social mobilization in defense of the welfare state in Spain since the introduction of democracy and maybe the strongest bulwarks against health inequalities. The second part of the text reviews almost exhaustively the academic literature and official data on the impact of the 2008 crisis on health inequalities, to conclude that the SNHS displayed considerable resistance to the effects of recession during the early years but its buffer capacity was exhausted by 2013, aggravating social inequalities and disproportionately affecting the most vulnerable populations. Two articles compare the cases of Spain and Portugal. Elena Cachón González analyses the impact of the crisis and austerity on health inequalities, combining objective indicators on health and health services with subjective indicators on quality of life related to health and also on the individual satisfaction with health services. The data shows that, although the objective indicators have improved once the crisis was overcome, the same did not occur with the subjective indicators because, among other reasons, the social determinants of health are still far from normal. Raúl Payá Castiblanque in turn, is

14 Mauro Serapioni, Pedro Hespanha particularly concerned with the effect of the crisis and austerity on the increasing rates of work accidents and the unequal ways in which this affects different groups in the active population. Two categories of workers are particularly hit in both countries: those in precarious sectors in the areas of construction and the industry, and those in small enterprises, especially young people. The case of Italy is scrutinised in two different articles, one by Stefano Neri, the other by Rossella De Falco. Stefano Neri examines the process of reform of the National Health Service (NHS) since the beginning of the 2008 crisis, with an aim to focus on the changes to NHS governance. The author illustrates the characteristics of the Italian health system and the main stages of the decentralization process from the State to the regions, highlighting the changing of their respective roles and the operation of the State- Region Conference, a mechanism of joint policy making between the central government and the regions. Neri also analyses the repercussions of the economic crisis on intergovernmental relations, explaining how the crisis strengthened the role of the central government (namely, the Ministry of Economy but indirectly also the European institutions) in the development of national policies, to the detriment of the role played by the regions. For the author, this change in intergovernmental relations could endanger the universalist nature of the Italian NHS and its capacity to guarantee the values of equity and solidarity, especially on a geographical level. From the perspective of human rights, Rossella De Falco studies the impact of post-2008 austerity policies on increasing inequalities in the Italian National Health Service. After describing the fiscal adjustments implemented by the government, the author examines key right-to-health indicators over the 2010-2016 period. Finally, based on the analysis of secondary data from national and international sources, De Falco focuses on the increasing level of unmet medical needs due to costs, waiting time, and increased user fees. The results, the author argues, evince how the regressive health policies undermine equitable access to care. To expand the reflection on the South initiated with the case of the SEC, the @cetera section presents two articles from the perspective of the global South (Santos, 2018), namely Brazil. These texts address the impact of neoliberal and conservative reforms implemented in recent years. The text by Tânia Krüger, entitled “Sistema Único de Saúde: redução das funções públicas e ampliação ao mercado”, illustrates the deconstitutionalization of the Unified Health System (SUS) as a result of the process of dismantling and privatisation of public health institutions and services. The author examines the recent counter-reforms hitting the SUS, presenting indicators that show how it is becoming subordinate to the private health sector. Rosana Mirales’s essay focuses on 21st century conservative thinking and its negative impact on both social services and professional training in this field of

15 Crisis and Austerity in Southern Europe: Impact on Economies and Societies intervention. Mirales looks into Josep Bacqués’s recent study El liberalismo- conservador. Fundamentos teóricos e recetario político ss. XVIII-XX with an eye to developing a critical analysis of the foundations of conservatism and its close ties to liberalism.

MAURO SERAPIONI Centro de Estudos Sociais da Universidade de Coimbra Colégio de S. Jerónimo, Largo D. Dinis, Apartado 3087, 3000-995 Coimbra, Portugal Contact: [email protected]

PEDRO HESPANHA Centro de Estudos Sociais da Universidade de Coimbra | Faculdade de Economia da Universidade de Coimbra Colégio de S. Jerónimo, Largo D. Dinis, Apartado 3087, 3000-995 Coimbra, Portugal Contact: [email protected]

REFERENCES Andreotti, Alberta; García, Soledad; Gomez, Aitor; Hespanha, Pedro; Kazepov, Yuri; Mingione, Enzo (2001), “Does a Southern Model Exist?”, Journal of European Area Studies, 9(1), 43- 62. Cabiedes, Laura; Guillén, Ana M. (2001), “Adopting and adapting managed competition: health care reform in Southern Europe”, Social Science and Medicine, 52(8), 1205-1217. Callan, Tim; Leventi, Chrysa; Levy, Horacio; Matsaganis, Manos; Paulus, Alari; Sutherland, Holly (2011), “The Distributional Eﬀects of Austerity Measures: A Comparison of Six EU Countries”, EUROMOD Working Paper Series, EM6/11. De Vogli, Roberto (2014), “The Financial Crisis, Health and Health Inequities in Europe: The Need for Regulations, Redistribution and Social Protection”, International Journal of Equity in Health, 13, article 58. Dirindin, Nerina . (2011), “La manovra sulla sanità: una dieta improvvisata inefficace”, Saluteinte Internazionale. Accessed on 30.05.2019, at http://www.saluteinternazionale.info/2011/07/la-manovra-sulla-sanita-una-dieta- improvvisata-e-inefficace/. Escolar-Pujolar, Antonio; Bacigalupe, Amaia; San Sebastian, Miguel (2014), “European Economic Crisis and Health Inequities: Research Challenges in an Uncertain Scenario”, International Journal for Equity in Health, 13, 59-61. Esping-Andersen, Gøsta (1990), The Three Worlds of Welfare Capitalism. Cambridge: Polity Press.

16 Mauro Serapioni, Pedro Hespanha

European Commission (2010), “The Economic Adjustment Programme for Greece”, Occasional papers, 61. Brussels: European Commission – Directorate-General for Economic and Financial Affairs. European Commission (2012), “The Fnancial Sector Adjustment Programme for Spain”, Occasional papers, 118. Brussels: European Commission – Directorate-General for Economic and Financial Affairs. European Commission (2014), “The Economic Adjustment Programme for Portugal, 2011-2014”, Occasional papers, 202. Brussels: European Commission – Directorate-General for Economic and Financial Affairs. European Commission (2015), “Memorandum of Understanding between the European Commission Acting on behalf of the European Stability Mechanism and the Hellenic Republic and the Bank of Greece”. Brussels: Directorate-General for Economic and Financial Affairs. Accessed on 23.09.2018, at https://ec.europa.eu/info/sites/info/files/01_mou_20150811_en1.pdf. Eurostat (2018), “Real GDP Growth Rate – Volume (tec00115)”. Accessed on 12.05.2019, at https://ec.europa.eu/eurostat/web/national-accounts/data/main-tables. Ferré, Francesca; de Belvis, Antonio Giulio; Valerio, Luca; Longhi Silvia; Lazzari, Agnese; Fattore, Giovanni; Ricciardi, Walter; Maresso, Anna (2014), “Italy: Health System Review”, Health Systems in Transition, 16(4), 1-168. Ferreira, António C. (2014), Política e sociedade: teoria social em tempo de austeridade. Porto: Vida Económica. Ferrera, Maurizio (1996), “The ‘Southern Model’ of Welfare in Social Europe”, Journal of European Social Policy, 6, 17-37. Giarelli, Guido (2006), “Il paradigma mediterraneo? Riforme sanitarie e società nell’Europa meridionale”, Salute e Società, IV(Supl.), 1-29. Guillén, Ana M. González Begega, Sergio; Luque Balbona, David (2016), “Austeridad y ajustes sociales en el Sur de Europa. La fragmentación del Modelo de Bienestar mediterráneo”, Revista Española de Sociología, 25(2), 261-273. Hespanha, Pedro (2017), “As reformas dos sistemas de saúde na Europa do Sul: crises e alternativas”, in Paulo Henrique Rodrigues; Isabela Santos (eds.), Políticas e riscos sociais no Brasil e na 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, and Health in Europe”, The Lancet, 381, 1323-1331. Leibfried, Stephan (1992), “Towards a European Welfare State”, in Zsuzsa Ferge; Jon Eivind Kolberg (eds.), Social Policy in a Changing Europe. Boulder: Westview Press, 245-279.

17 Crisis and Austerity in Southern Europe: Impact on Economies and Societies

León, Margarita; Migliavacca, Mauro (2013), “Italy and Spain: Still the Case of Familistic Welfare Models?”, Population Review, 25(1), 25-42. Maciocco, Gavino (2015), “Assalto finale al Servizio Sanitario Nazionale”, Salute Internazionale, 26th October. 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 de saúde 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 y efectos 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 Healthcare Systems 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 Structural Reforms 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 das políticas 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. Silva, Pedro Adão (2002), “O modelo de Welfare da Europa do Sul”, Sociologia, Problemas e Práticas, 38, 25-59. Titmuss, Richard (1958), Essays on the Welfare State. London: Allen and Unwin. Titmuss, Richard (1974), Social Policy. London: Allen and Unwin.

18 e-cadernos CES, 31, 2019: 19-42

MARIA PETMESIDOU

CHALLENGES TO HEALTHCARE REFORM IN CRISIS-HIT GREECE

Abstract: This paper critically examines the health reform trajectory in Greece in the last decade. The first part provides an overview of the Greek healthcare system shortly before the crisis, with an emphasis on the incomplete development of a national health system beset by inequalities in coverage and funding. At the backdrop of the crippling debt-crisis that engulfed the country in the late 2000s, the second part of the study tracks the major healthcare reforms under the successive bailout packages. These are examined from the point of view of whether they can secure the public system’s long-term viability and promote equity, or if they contribute to its withering away instead. The third part of the article looks at the impact of the austerity-driven reforms on inequalities in healthcare, highlighting some major findings regarding health outcomes. Keywords: austerity, health funds, inequalities in healthcare, national health system, out- of-pocket payments.

DESAFIOS À REFORMA DOS CUIDADOS DE SAÚDE NA GRÉCIA AFETADA PELA CRISE

Resumo: Este artigo analisa criticamente a trajetória da reforma da saúde na Grécia na última década. A primeira parte apresenta uma visão geral do sistema de saúde grego em vésperas da crise, com ênfase no desenvolvimento incompleto de um sistema nacional de saúde marcado por desigualdades na cobertura e no financiamento. No contexto da debilitante crise de endividamento em que o país mergulhou, no final da década de 2000, a segunda parte do estudo acompanha 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 do sistema 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 das reformas orientadas pela austeridade sobre as desigualdades nos cuidados de saúde e destaca-se algumas das principais conclusões sobre os resultados em matéria de saúde. Palavras-chave: austeridade, desigualdades nos cuidados de saúde, fundos de saúde, pagamentos do próprio bolso, sistema nacional de saúde.

19 Maria Petmesidou

1. INTRODUCTION Greece has suffered the most severe consequences of the crisis that followed the global financial meltdown of 2008. The country went through an eight-year program of external financial assistance by the European Commission (EC), the European Central Bank (ECB) and the International Monetary Fund (IMF), the so-called Troika, in exchange for strict austerity measures and structural adjustment across a large spectrum 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 about 19% 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 highest in 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 the years ahead will deprive the economy of serious resources in the road to recovery. On August 20, 2018 Greece formally exited its bailout program. Yet as the country is highly indebted to the European official sector (close to €260 billion), “enhanced” surveillance by the international lenders will continue (IMF, 2018; EC, 2018a). Compared to the other Euro area countries that went through a financial bailout, in Greece post-program surveillance will be of higher frequency (on a quarterly basis) and the monitoring of specific policies stricter.2 For a long time, the Greek healthcare system was stuck halfway between a highly fragmented social health insurance and a national health service model. In the early 1980s a universalist national health system ESY (Ethniko Sistima Ygeias) was introduced. However, until lately, the ESY hardly reached the state of a fully-fledged national health service. Both in terms of funding and service delivery a mixed system continued to operate: an occupation-based health insurance system combined with a national health service, but private provision was expanding too (mostly out-of-pocket payments as private health insurance remained negligible). The economic and financial crisis that engulfed the country as well as strong outside pressure by the international lenders brought reform, along the lines of the “path shift” introduced in 1983, high on the agenda. This precipitated changes, such as the unification of health funds, the standardization of contributions and the equalization of the benefits package across socio-occupational groups. Yet, at the same time, rising user charges, rolling back of

1 This is a dismal performance compared to the other South European countries, which were badly hit by the crisis too. In Portugal GDP (in real terms) reached its 2008 level in 2018, and in Spain 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).

20 Challenges to Healthcare Reform in Crisis-Hit Greece public provision, and rationing through increasing waiting times and other blockage mechanisms have a negative impact on access, equity and service quality. 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 opportunity that 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 and allocation of financial resources to providers, and (b) the structure and governance of provision. A major question addressed is whether the ongoing reforms can enhance and sustain universalism, or instead do they contribute to the withering away of a public system, which, anyway, never in the past embraced strong universalistic principles. Corroborating evidence of a bleak future is manifested by data on increasing inequalities in healthcare regarding accessibility to and affordability of health services.

2. THE CRISIS AS CATALYST: AN ANALYTICAL CONTEXT Two analytical accounts of policy reform are illuminating for understanding: a) why the path shift towards a national health system has for a long-time remained a half way reform in Greece, and b) which dynamic underlies the attempts to complete the reform in the last few years, though amidst severe fiscal retrenchment. These consist in Thelen’s conceptualization of “institutional layering” (2004), and Kingdon’s analysis of “windows of opportunity” for policy breakthroughs (1995).3 As extensively shown in the social policy literature, institutional arrangements are characterized by a considerable “stickiness”. They consolidate interests and commitments that create “veto” points, which highly increase the political (and often also the economic) cost of change (see Pierson, 1996; also Wilsford, 1994 on “Path dependency”). Critical junctures due to economic and/or political crises provide windows of opportunity for major reforms. However, for this to happen there needs to be an alignment favorable to change between three components: actors, institutions and ideas. Namely, there needs to be problem recognition by actors, willingness/ability to act and availability of policy ideas (Kingdon, 1995). Furthermore, as Thelen (2004: 35) has shown, incremental change, particularly in the form of “institutional layering” (that is, adding a new “layer” on an otherwise stable institutional setting) can be a driver of transformation too, particularly in the long run. Under certain conditions, if this “layering” process takes place in a prolonged period it can “significantly alter the overall trajectory of an institution’s development” (ibidem).

3 For a detailed analysis of the political and policy dynamics in Greece, at various stages of the evolution of the healthcare system since the restoration of democracy in the mid-1970s, see Petmesidou (forthcoming).

21 Maria Petmesidou In the realm of health politics and policy, in Greece, three reform efforts are of crucial importance: a) the introduction of ESY in the early 1980s; b) a failed attempt to revive reform momentum for completing the shift towards a national health system in the early 2000s; and c) a crisis-driven reform under the bailout program. A few years after the restoration of democracy in the country, the introduction of a national 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/ability to pursue the breakthrough initiated by Law 1397 of 1983 that established ESY. PASOK consolidated its dominant position in the Greek political system by effectively rebuilding/expanding clientelist relations, a condition that hardly allowed even a minimum consensus among social actors about how to articulate redistributive issues along the lines of universalist citizenship values and criteria.

Hence, a watered-down version of the reform was implemented. This was a politically expedient solution as the government was confronted by strong veto points within the medical profession and the privileged health insurance funds (mostly sickness funds of employees in public banks, telecommunications and other public enterprises). Major stipulations in the law, such as uniform funding and service provision for all citizens, the gradual absorption of the private by the public sector, and a more balanced regional distribution of health infrastructure and personnel remained largely on paper, and the reform did not significantly change the status quo in health insurance. Universal access was limited to hospital care. Primary care was neglected, largely provided by the private sector, the health centers of IKA (the Social Insurance Organization for the majority of private sector employees), as well as by medical practitioners contracted by various sickness funds. Private spending continued to rise, and many privileged health insurance funds maintained their prerogatives. Thus, quite soon after the proclamation of a radical reform, social policy returned to its old patterns. Following Thelen (2004), we would argue that the reform added “a new ‘layer’ (universalist healthcare) onto an existing stable institutional framework (a splintered health insurance system)” (Petmesidou, forthcoming). In the context of a political dynamics heavily relying on statist/clientelist practices, instead of this process triggering a momentum of policy breakthrough over time, it sustained a “disjointed

22 Challenges to Healthcare Reform in Crisis-Hit Greece pattern” with low degree of institutional coherence and prevalent path-dependent features, over the following two decades (ibidem). Diversity of coverage, multiplicity of funding and system fragmentation persisted and accounted for lack of coordination of purchasing policies, soaring ESY deficits, alarmingly rising pharmaceutical expenditure and other system predicaments. At the turn of the century, an initiative by the Ministry of Health, under the then PASOK government, to tackle fragmentation, rationalize and de-concenter decision-making and control, and regulate relations between key health actors met strong opposition from various quarters, even within the government. This caused the resignation of the Minister of Health and the downsizing of reform ambitions. The deep economic and financial crisis significantly reshuffled political relationships. Strong outside pressure by the country’s international lenders made it imperative for the government to push through reforms, in tandem with harsh cuts in funding and receding public provision. Under the bailout program a (more or less forced) alignment between the three spheres mentioned above – institutions, actors and ideas – has occurred. This created a window of opportunity that made long- overdue reforms possible (Petmesidou, forthcoming). Amidst a severe economic and financial crisis, the resources for clientelist exchanges significantly diminished, the legitimacy of political parties, trade unions and other major political actors waned, and the party system exhibited a deep systemic crisis (Petmesidou, 2017: 157). Moreover, the bailout deal imposed an upward shift in decision-making for major reforms to the international lenders (and mainly to the crisis-management apparatus of the EU). The role of the executive was strengthened, while the ability of trade unions, associations, and other “veto” groups to sway political decisions significantly weakened (Petmesidou and Glatzer, 2015: 170-176). Moreover, the bailout conditions allowed the government to shift the blame of reform and austerity to the Troika, in order to shield itself from political 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, the IMF and the World Health Organization (WHO), which played a crucial role in guiding policy. The combination of the above factors facilitated a coupling of the three major streams in policy. Namely, under the sovereign debt crisis, the shift in the power and decision-making dynamics forced political actors to recognize the system’s functional deficits, made imperative for them to act, and set the policy options.

23 Maria Petmesidou

3. THE REFORM TRAJECTORY

3.1. TRENDS IN HEALTH EXPENDITURE – MAIN DIMENSIONS OF REFORM Soaring deficits by public hospitals and rapidly increasing pharmaceutical expenditure over the 2000s greatly strained the state budget. In the decade prior to the eruption of the crisis, per capita total health expenditure (measured in constant Purchasing Power Parities, PPPs) grew on average annually by about 6.6% (EU15 average: 3.6%; Petmesidou, forthcoming). Markedly, average yearly per capita private spending rose faster than public spending (by 7.7 and 5.8% respectively). Especially high was the rate of growth of per capita pharmaceutical spending: 11.1% yearly on average (in constant PPPs) 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 the corresponding rates for the EU15 and the other three South European countries (Table I). 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 been debated since the inception of ESY in 1983, but never materialized, such as devolution, integration of primary and secondary care, reduction of fragmentation in health insurance, etc. The changing demographic makeup is also a matter of concern as Greece is set to experience rapid ageing in the coming decades: the share of the 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 medical technology advancement and rising expectations for quality provisions and choice, population ageing will increase pressure on public spending (particularly on chronic diseases and geriatric and personal care).5 Strict ceilings were set in the EAP for total public health financing and its constitutive schemes – for instance, total public health spending is capped at (or below) 6% of GDP and pharmaceutical expenditure at about 1% of GDP, which however has shrunk by a quarter since 2010, as mentioned above. From 2009 to 2017 total health spending (in current 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 €9.1 billion).6 This is a rather steep contraction compared to the other three

4 In 2009, outpatient pharmaceutical expenditure amounted to roughly about 40% of total public health 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.

24 Challenges to Healthcare Reform in Crisis-Hit Greece South European countries, 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 peak rate 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 health 2826/ 2651/ 2885/ 3103/ 3860/ 2015 2515 2981 3033 4084 expenditure 1960 2340 2722 2965 3936

Public health 1937/ 1854/ 2175/ 2430/ 3055/ 1233 1676 2110 2245 3186 expenditure 1218 1566 1933 2255 3054

Private health 889/ 798/ 710/ 673/ 804/ 781 839 871 788 899 expenditure 726 774 789 710 881 Total expenditure 834/ 635/ 639/ 588/ 686*** 625 474 674 625 642 on medical 567 461 620 588 /623 goods** Public expenditure 648/ 351/ 306/ 313/ 436*** 367 231 324 353 391 on medical 337 229 229 322 /370 goods** Average yearly change of per capita expenditure (constant PPPs, OECD base year*)

2009-2013 2013-2017

Greece Portugal Spain Italy EU15 Greece Portugal Spain Italy EU15

Total health -8.7 -3.1 -1.4 -1.1 0.5 0.7 1.8 2.3 0.6 1.7 expenditure

Public health -11.0 -4.1 -2.9 -1.8 0.0 0.3 1.7 2.2 -0.1 1.1 expenditure

Private health -4.9 -0.7 2.7 1.3 2.1 1.9 2.0 2.5 2.6 0.5 expenditure Total expenditure -9.3 -7.7 -0.8 0.0 - 3.3 0.9 2.8 1.6 1.0 on medical goods** Public expenditure -15.1 -10.2 -6.3 0.7 - 2.9 0.3 1.2 2.4 1.8 on medical goods**

Notes: *Constant prices (2010), constant PPPs (2010), in US dollars. ** Mostly pharmaceuticals (for Greece, Portugal, Spain and EU15 most recent data for expenditure on medical 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.

Between 2009 and 2013, per capital public health spending, in real terms, contracted by 11% on average annually, and stagnated afterwards. Thus, in 2017 per

25 Maria Petmesidou capita total health spending dropped to about half that of the EU15, and per capita public expenditure to a third of the respective EU15 average (Table I). Equally sharp has been the decline of per capita public spending on medical goods (mostly pharmaceuticals, in PPPs and constant prices). Private spending (out-of-pocket – including informal – payments and private health insurance premiums, the latter of limited importance though) stood at €7.1 billion in 2009 (Figure I). It decreased until 2012, but it then resumed a slight upward trend, despite falling household incomes until recently. In 2016, private spending amounted to about 40% of total health spending, compared to about 30% in the other three South European countries, and to 24% in EU15 (Figure II). Taking also into account the persistently low degree of satisfaction with public health services (Petmesidou et al., 2014: 333-335; Eurofound, 2017: 54-56), extensive reliance on private spending highly questions whether a truly universal system has ever been in place in Greece.

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

Government 10.000 Social health insurance 9.000 Voluntary health insurance 8.000 Out-of-pocket 7.000 6.000 5.000 4.000

billion euros 3.000 2.000 1.000 0

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

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/-.

26 Challenges to Healthcare Reform in Crisis-Hit Greece

FIGURE II – Percentage Constitution of Health Care Financing

Other 100 Out-of-pocket payments 90 Voluntary Health 80 insurance Social Insurance Funds 70 Government 60 50 40 30 20 10 0 Greece, Greece, SE, 2016 EU-15, 2016 2009 2016

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

The crisis intensified financial, organizational and equity problems that characterized healthcare in the country for several decades. Most importantly, great diversity in the range and quality of provisions among the plethora of sickness funds kept inequality high.7 Since 2011, in the context of the reform dynamics briefly highlighted above, a number of measures have been introduced, apparently in order to tackle major system deficiencies. However, a controversial trend is clearly manifest. Steps are taken 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 cost away 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 deep cuts 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).

7 As Petmesidou and Guillén stated (2008: 115): “in 2006 health care expenditure (including health 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 Insurance Organization) and some of the ‘noble funds’ for public utility employees, like those in telecommunications and electricity, were 635, 648, 1,040 and 980 euros respectively”.

27 Maria Petmesidou On the funding side, a major structural reform consists in the separation of the health from the pension branches of social insurance funds and the merging of the former into a unitary organization (the National Health Services Organization, Greek acronym EOPYY, legislated in 2011), to act as a single purchaser of health services. This was accompanied by the equalization of contributions and the standardization of the health benefits basket across occupational groups. Also, mechanisms of monitoring and control of services were put in place, facilitating a tighter spending oversight. Changes in the allocation arrangements, by which funding is transferred to services providers, were also implemented, particularly regarding hospital payment systems. On the organizational/governance side, consolidating hospitals into larger units, re- configuring cost-accounting and management, as well as integrating primary and secondary care have been varyingly implemented so far. Of significant importance is a three-year plan to overhaul primary care, which started being rolled out in 2018. The aim 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. The Greek health system has persistently been highly centralized. Despite the establishment of Regional Health Authorities (YPEs in the Greek acronym) in the early 2000s, plans to devolve responsibility for the operation and management of health units failed to materialize. Recent reforms disclose a two-way trend: The pooling of health insurance contributions through the creation of EOPYY indicates a move towards centralization, while the assignment of control over primary care to YPEs points in the direction of decentralization. However, it remains to be seen whether the latter move will be backed by the devolution of real decision-making power.

3.2. FUNDING SIDE CHANGES: HOW HEALTHCARE REVENUE IS RAISED AND ALLOCATED TO SERVICE

PRODUCERS Health financing derives from three sources: taxation – over 50% of it being indirect taxes in 2017 (Independent Authority for Public Revenue, 2017: 2 and 6) –, social insurance contributions and private, mostly out-of-pocket, spending. Between 2009 and 2016, we observe a significant change in the composition of healthcare financing with the 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 and inability to pay contributions by a significant number of self-employed and small businesses account for the decline of health insurance revenues. Moreover, extensive reliance on out-of-pocket payments and indirect taxation renders the system highly regressive.

28 Challenges to Healthcare Reform in Crisis-Hit Greece From 2011 to 2016, the amalgamated pension branches of social insurance funds were responsible for collecting contributions, which then were transferred to EOPYY. In 2017, this function was undertaken by a new body (the Unified Body of Social Insurance, Greek acronym EFKA,) responsible for the collection of health and pension insurance contributions. EOPYY should maintain a balanced budget, as state subsidy is henceforth confined to the organization’s operational costs (around 0.4% of GDP; Economou et al., 2017: 56; see also Karakolias and Polyzos, 2014).8 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 of Health. Initially the organization was also responsible for the management of primary care (the healthcare centers previously belonging to the health insurance funds). But in 2014, a split took place between insurance-purchasing functions retained by EOPYY, and primary and ambulatory care provision undertaken by a new organization, the National Primary Healthcare Network (PEDY, the Greek acronym). Potentially, as the single purchaser of publicly provided healthcare services, EOPYY could weigh heavily on bargaining with suppliers. But its powers are greatly limited as decisions rest with the Ministry of Health in a context of highly centralized collective bargaining with suppliers’ associations.9 The State budget covers the salaries of health and administrative personnel in public hospitals, primary/ambulatory care in local health units, health centers and outpatient departments, and capital investment. It also provides subsidies to public hospitals and EOPYY, 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 of diagnostic related groups (DRGs). EOPYY also funds service provision by contracted physicians, private diagnostic laboratories and clinics. Regulatory mechanisms introduced include: a) budget ceilings for EOPYY accompanied by a clawback/rebate mechanism for private providers (pharmacies, pharmaceutical companies, diagnostic laboratories and private clinics) so as to keep expenditure within the budget limits;10 and b) thresholds on physicians’ activity (limits in

8 A tiny number of health insurance funds did not join EOPYY (and EFKA). These include the health 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) sets limits to EOPYY’s status as an independent organization, through the establishment of a special department in the Ministry of Health, accountable directly to the Minister of Health and responsible for overseeing a wide spectrum of decisions concerning EOPYY’s budget, the terms and conditions under which private practitioners, diagnostic laboratories and private clinics are contracted, and other activities. 10 A clawback system requires pharmaceutical companies, private diagnostic centers and clinics, 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 than in 2017.

29 Maria Petmesidou the number of referrals for diagnostic tests, compulsory prescribing by active substance, and electronic monitoring). The introduction of e-governance tools and attempts to make the public procurement system more transparent and efficient are also among the main cost- containment measures. However, in the absence of systematic health needs assessment at different levels (e.g. regional, local), caps on referrals and prescriptions per specialty (and prefecture), in place in the last few years, are drawn in a rather ad hoc way. For instance, according to a recent Ministerial Circular11 average monthly per capita prescription 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 any sound evidence of demographic and morbidity trends is the fluctuation of rates per prefecture/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%. Co-payments for pharmaceuticals more than doubled, from about 10 to 25% (plus an extra charge of €1 per prescription), and a 15% co-payment for diagnostic and laboratory tests in contracted centers was introduced. Exemptions from co-payments (or lower rates) apply to individuals and families with very low income (including the uninsured with low income) and some vulnerable groups (e.g. people with chronic diseases) on the basis of income criteria.12 At the same time, existing exemptions from user charges for some groups were lifted. For instance, for the chronically ill persons exemptions are strictly related to their chronic illness, even though some of their ailments maybe an indirect consequence of their health conditions (Petmesidou, 2014: 20). Other major measures for lowering prices and volumes of pharmaceuticals embrace the establishment of a drug-pricing observatory and a reference pricing system that sets the 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; the reduction of the profit margin for pharmacies; and ceilings in physicians’ prescriptions, as stressed above. An entrance fee of €3 for outpatient care, introduced in 2010 (and increased to €5 in 2011), as well as a €5 fee charged for every hospital admission since 2014, were abolished in 2015. But private outpatient clinics, run within public hospitals in the afternoon, charge fees per visit, which, however, are not covered by social insurance. In the last few years, the rising number of visits to afternoon clinics of public hospitals is

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).

30 Challenges to Healthcare Reform in Crisis-Hit Greece the result of long waiting lists for free access to specialists. Also, since 2012, patients who receive treatment in private hospitals/clinics contracted by EOPYY must pay 30% of the total cost. Informal payments have persistently been a major component of out-of-pocket payments keeping private spending high and exacerbating inequalities in care. They are common for skipping waiting lists and as undeclared cash payments to physicians and surgeons. Comparatively low salaries of ESY health personnel in Greece vis-à-vis other 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 in the health sector (defined as the aggregate of “graft, fraud and under-the-table payments” in the public and private sector) at about €4 to €5 billion annually, during the decade of the 2000s. This should total approximately €50 billion in the end of the decade, an astonishing amount that is equal to the cumulative public deficit from 2003 to 2009 (ibidem). Even though this estimate should be taken with caution, it provides a glaring indication of the serious inefficiencies of the healthcare system. Nevertheless, it is worth noting that, despite measures for combating systemic problems, and the strains on household incomes during the crisis, the practice of under-the-table payments continues unabated. A survey conducted in 2012 “reports under-the-table payments 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 private practitioners and dentists (ibidem; see also Liaropoulos et al., 2008). In a nutshell, considerable improvements in rationalizing funding accrue to the pooling of resources, the establishment of a single payer, the shift from retrospective reimbursement for secondary health service provision (based on the patient cost per specialty) 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 of need, drawing upon demographic, socio-economic and epidemiological data has hardly been in place. YPEs could potentially play a crucial role in developing needs assessment mechanisms, provided their budgetary and planning competences are strengthened. A Health and Welfare Map to monitor health needs, allocation and use of resources that could feed into policy decision-making has been on the agenda of the Ministry of Health since the early 2000s, but with very little progress so far.

3.3. INSTITUTIONAL/ORGANIZATIONAL ARRANGEMENTS IN SERVICE PROVISION Organizational reform embraces: a) a two-way trend of centralization/decentralization of administrative and governance functions and controls, and b) a consolidation of secondary care providers into larger units.

31 Maria Petmesidou

3.3.1. A Two-Directional Trend The split trend along the first dimension consists, on the one hand, in: the pooling of financial resources through the establishment of EOPYY (and, later on, of EFKA); the centralization of decision-making and control over the range of service provision and resource allocation methods; and the ongoing trend of centralized procurement of medical supplies and devices so as to reduce less-than-optimal outcomes and improve transparency. Also, new information systems – such as electronic platforms for collecting/monitoring data on performance – accompany centralization policies of governance. Though, so far, these do not embrace any quality indicators and quality assurance strategies. On the other hand, legislation for primary care enacted in 2014 transferred responsibility for primary care coordination to regional health authorities. The law provided for the redrawing of the primary care map by creating a mixed-system of providers embracing the about 200 hundred rural surgeries (transferred from ESY to PEDY), 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, the networking plan was hardly implemented. A significant reduction of the medical staff in the ex-EOPYY health centers considerably limited public service provision. The reduction in staffing levels was caused by the change in the employment conditions for medical doctors under PEDY. Physicians employed in the ex-EOPYY units were asked to choose whether to become full-time employees in the National Primary Healthcare Network and close down their private practice, or else terminate their participation in the 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 in PEDY, while those who served under IKA and EOPYY for over 15 years be allowed the option of combining private practice with provision of services in PEDY units until they retire. Eventually the reform bill turned into law, as this was a policy stipulated by the bailout package, and a significant number of physicians of urban health centers chose not to join the new organization. In 2017, new legislation passed by the coalition government between SYRIZA (Coalition of Radical Left) and ANEL (Independent Greeks, a small, far-right populist party) added a 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 and strengthen primary prevention and health promotion activities. Under the new plan, PEDY units will function as a second-tier ambulatory care. TOMYs, together with contracted private physicians (general practitioners, pathologists and pediatricians) will establish a local gate-keeping network, targeting family doctor

32 Challenges to Healthcare Reform in Crisis-Hit Greece services for all. Once more, an attempt is made to integrate primary care into the public system and counteract overreliance on specialist and inpatient care. However, the implementation of the plan is beset with problems. The time-span of budgetary provision for the operation of TOMYs is limited (up to four years maximum) and funding is tied to EU sources. Besides, adequate infrastructure is hardly available in many localities. Similarly, to other services relying on EU sources (e.g. the Home Help program), there is the risk of service discontinuity when EU funding stops. These uncertainties account for the low response by doctors (even junior ones facing unemployment) to repeated calls by the Ministry of Health for filling positions in TOMYs.13 Equally difficult has been so far to attract private practitioners to the local primary care network, to be contracted family doctors. Significant changes in EOPYY’s contract conditions (lower earnings for higher workload and restrictions on private practice) met with the reluctance of private practitioners to join the planned primary healthcare network. As stressed in a recent report (EC, 2018c: 36), “slow progress may increase the risk of future discontinuation or reversal”.

3.3.2. Consolidation of Secondary Care Providers Re-configuration of secondary healthcare service providers has been on the way during the last few years with the aim to contain cost and rationalize structure and governance. Policy measures embrace the redrawing of the hospitals map, by combining them into fewer units under common administration, the cutting down and/or rearrangement of clinics and functional beds, changes in the function of several ESY healthcare facilities, staff relocation and redistribution of heavy equipment across hospitals. However, so far, these policies have limited implementation, and according to a recent study their positive effect on overall hospital efficiency has not been significant (Kaitelidou et al., 2016). Efficiency improvement is also sought by measures such as the introduction of a double-entry accounting system for costing services, the all-day functioning of hospitals, extension of working hours of outpatient offices, and the revision of emergency and on-call duty. Notably, staff shortages have intensified, due to hiring freeze for several years, and persistent reliance on term-contract appointments of health personnel. Most importantly, the shortage of nursing staff seriously affects service delivery – in some of the main hospitals in Athens cutbacks have left one nurse to look after 20 or more patients (Petmesidou, 2014: 19). Greece ranks last among the EU28 countries in terms of the ratio of nurses per 1,000 population (3.2 in 2014, EU28 average 8.4). Staff

13 In late 2018, only about 100 TOMYs (from a planned total of 240 units) started operating.

33 Maria Petmesidou shortages also 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 hospital beds must be in intensive care units. In Greece, the rate is close to 2%, while over a fifth of them are not in operation due to qualified staff shortages.14 Overall, major challenges remain with regard to the deployment and management of resources, coordination with primary care, response to need, and quality of services.

4. INEQUALITIES OF HEALTHCARE: ACCESSIBILITY AND AFFORDABILITY Austerity-driven cuts and reforms cast doubts on the “universal” character of the system. Equalization of provision across social insurance funds was accompanied by a significant review of the range of public provision, leading towards a low common denominator. This shifted provision to the private sector and, in tandem with significant inequalities in the geographical distribution of public health facilities, greatly impacted upon accessibility to and affordability of healthcare. Importantly, the crisis conditions brought to the fore the serious problem of a rapidly increasing number of uninsured people. In 2013, it was estimated by EOPYY (Petmesidou et al., 2014: 345) that there were about 2.5 million people lacking healthcare coverage. These included the long-term unemployed and their dependents, people who filed business bankruptcy, or who might still run a business but were unable to pay contributions due to severe hardship, and legal/illegal immigrants and refugees. In 2013, a program was launched providing (on a means-tested basis) vouchers that allowed uninsured persons and their dependents to have access to primary and ambulatory care. However, eligibility and range of ambulatory provisions were limited, inpatient care was not covered, and the scheme fell short of covering need. In 2016, new legislation lifted most barriers for uninsured citizens in accessing outpatient and inpatient publicly provided care. Nevertheless, as the uninsured are barred from contacting private providers contracted by EOPYY, inequity of access persists, especially in regions/localities with staff shortages and lack of diagnostic equipment in public health facilities. Increased co-payments and fees as well as long waiting lists also function as rationing measures creating barriers to access. In certain prefectures, the quicker appointment one can get for seeing a pathologist or a cardiologist in EOPYY could be in two or more weeks, while in the national hospitals network it might take even longer (Petmesidou, 2014: 23). Particularly long are waiting times for heart surgery: on

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.

34 Challenges to Healthcare Reform in Crisis-Hit Greece average, two to four months across the country, but in certain cases waiting may reach or surpass six months (Boulountza, 2016). A ministerial decision issued in late 2016 made obligatory a more transparent use of priority medical criteria for waiting lists. Public hospitals have started 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 PEDY health centers is another blockage mechanism. Household expenditure data of the lowest income quintile show that, in the beginning of the crisis, average equivalized monthly health spending was a little over 10% of total consumption expenditure.15 It sharply dropped to about 7% in 2012, but increased afterwards 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 from 2009 onwards. With regard to the constitution of average monthly spending on healthcare by households in the lowest income bracket (up to €750 monthly), a striking 60% concerns pharmaceuticals (and medical devices), about 25% payments to physicians, and the rest mostly inpatient care in private hospitals and clinics. As healthcare demands are inelastic, significant cuts in public provision made necessary even among poorer households to spend a growing part of their monthly income in order to cover healthcare needs. In the available literature, a threshold of 10 to 15% (or over) of household monthly income (or consumption) spent on out-of-pocket healthcare payments is considered to be a “catastrophic” and “impoverishing” cost for households (see Xu et al., 2007). A case study conducted by Grigorakis et al. (2017) on the basis of a sample of people covered by mandatory social insurance, who “were hospitalized at least once in private providers contracted by EOPYY”, highlights the high risk of “catastrophic health costs”. About a third of their respondents declared having incurred a cost amounting to over 30% of their monthly income for health 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 et al., 2013 and 2014; Petmesidou et al., 2015: 295-342) also show that a substantial number of people discontinue medication or lower their doses, as they cannot afford the cost, with perilous effects on their health though. The geographical distribution of health facilities and personnel is a major dimension of unequal access. Among EU countries, Greece exhibits a high ratio of practicing physicians per 1,000 population (6.3, almost double the ratio EU28, in 2015), the vast majority of whom are specialists. There are very few general practitioners, and

15 ELSTAT data accessed on 15.10.2018, at http://www.statistics.gr/el/statistics/-/publication/SFA05/-.

35 Maria Petmesidou shortage of nursing staff is a persistently serious problem, as indicated earlier. Figure III shows the high concentration of health personnel in the two regions with the largest urban centers (Attica and Central Macedonia), as well as in two regions with well- established medical schools (Epirus and Kriti). It also depicts the prevalence of disability (and chronic diseases) by region (latest available data from an ad hoc study of disability carried out by ELSTAT in the early 2000s). Strikingly, the regions with the highest rates in the prevalence of disability score lowest in terms of health personnel per hundred thousand inhabitants. Inequalities in the spatial distribution of health facilities are compounded by the problem of physicians’ brain-drain since the eruption of the crisis (see Ifanti et al., 2014). According to the most recent available data, until mid-2018 about 12,700 physicians (mostly specialists) left the country.16

FIGURE III – Regional Distribution of Health Personnel (2016) and Prevalence of Disability

Medical 1000 20 doctors 900 18 Nurses and midwives 800 16 Prevalence of 700 14 disability (%) 600 12 500 10

400 8 inhabitants 300 6 perecentage 200 4 100 2

0 0 Health personnel per hundred thousand thousand hundred per personnel Health

Kriti Attiki

Ipeiros

Thessalia Ionia Nisia

North Aigaio South Aigaio Peloponnisos Sterea Ellada

Western Ellada

Central Makedonia Western Makedonia Eastern Mak&Thraki

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.

Barriers to accessing public health services in a time of crisis and inability to get medical treatment in the private sector (because this is unaffordable for people in economic hardship) seriously increase unmet need for medical care. This is reflected in the 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 were mostly immigrants. Only about 4% of Greeks sought “street medical care”. Yet, amidst

16 Data obtained from the Athens Medical Association.

36 Challenges to Healthcare Reform in Crisis-Hit Greece the crisis, estimates indicate that about a third of the Greek population turn to such clinics or seek support for covering their healthcare bills (Petmesidou, 2014: 24; see also Petmesidou et al., 2015: 269-293; Adam and Teloni, 2015). In the lowest income quintile unmet needs for medical examination have steadily increased from 2008 onwards (Figure IV). In 2017 close to a fifth of this income group declared 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 European countries (and to the EU28 average) unmet needs have been most prevalent in Greece until recently. It is noteworthy also that, in the last few years, the intensification of refugee (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 or long waiting list”)

(A) First (Lowest) Income Quintile (B) Third Income Quintile

2008 20 20 2008 2014 2014 2017 15 2017 15

10 10 5 5 0 0

EU28 Italy Italy Spain EU28 Spain Greece Greece Portugal Portugal

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

Although life expectancy at birth steadily increased over the last decades (81.5 years in 2016, 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, at the same time, there is evidence that austerity measures have significantly impacted upon the decrement in the populations’ health. According to the Global Burden of Disease Study (2016: e404), “from 2010 to 2016, Greece was faced with a five-times greater 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 in communicable, maternal, neonatal, and nutritional diseases since 2010”

17 A study by Zavras et al. (2016: 5), referring to the early years of the crisis, found that, for the total population, “the odds of unmet needs due to financial reasons were 44% higher in 2011 as compared with 2006”.

37 Maria Petmesidou (ibidem; see also Laliotis et al., 2016). Undoubtedly, it is rather difficult to disaggregate potential root cause factors of these outcomes (i.e. demographic profile, long-standing system specific characteristics, and the effects of austerity measures). Nevertheless, the fact that the worsening of public health takes place in tandem with a sharp reduction in public health spending and provision, makes it highly likely for the latter to have played a major role in the deterioration of the population’s health conditions.

5. CONCLUSION For a long-time health insurance and healthcare in Greece followed a splintered pattern. In the early 1980s, on a highly fragmented health insurance system, a layer of universalist healthcare was introduced. However, inequalities in the scope and coverage among socio-occupational groups persisted, and the path breaking reform of the introduction of ESY hardly managed to become a driver of wholesale change towards a fully developed national health system. Instead a “disjointed” configuration prevailed. This combined limited application of the principle of universal access with fragmented and unequal health insurance, in tandem with rapidly rising private, out-of- pocket payments. The statist-clientelist mode of socio-political integration that characterized the country for many decades accounts for the consolidation of strong “veto” points resisting change. Subsequent reform attempts in the decades of the 1990s and the 2000s made little progress in tackling inherent system inequities and financing/organizational deficiencies. The crisis provided a window of opportunity for promoting system integration, as envisaged by the 1981 reform, yet under conditions of sharply declining public spending 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, while traditional veto players, such as major trade unions and privileged health insurance funds, were sidelined. At the same time convergent policy options among EU countries guided reform towards: a) strict cost-containment and control measures shifting the cost to patients, and b) a two-pronged approach to governance consolidating service providers but also decentralizing administration and management. Undoubtedly, reforms increased system rationalization but blunt ceilings set by the bailout package drastically compressed the scope, quantity and quality of services. Seemingly, unification and standardization of health insurance aimed to tackle inequalities in coverage and access. But shrinking public provision runs counter to this. Unmet need for medical care greatly increased among lower-income groups (with a

38 Challenges to Healthcare Reform in Crisis-Hit Greece noticeable rise also among middle-income groups) and inequalities in terms of accessibility to and affordability of services deepened. Mandatory, state-regulated complementary insurance through the market is absent and the risk of catastrophic out- of-pocket payments appears to be high, particularly so, as “reforms increasingly co- opted universal public healthcare into private operators” (Petmesidou, forthcoming). Greece’s post-bailout commitments stipulating strict fiscal targets for the years ahead, in order for the country to service its huge public debt, leave little room for any policy options, in the near future, which could reverse course and harness the potential of reform for enlarging the scope and improving quality of universal healthcare.

MARIA PETMESIDOU Emeritus Professor of Social Policy, Department of Social Administration and Political Science, Democritus University of Thrace P. Tsaldari 1, Komotini 69100, Greece Contact: [email protected]

Received on 13.12.2018 Accepted for publication on 02.05.2019

REFERENCES Adam, Sofia; Teloni, Dimitra Dora (2015), Solidarity Clinics in Crisis-ridden Greece: The Experience of Health Care Provision when Public Health Care is in Retreat [in Greek]. Athens: INE-GSEE – Observatory on Economic and Social Developments. Accessed on 25.09.2018, at https://www.inegsee.gr/ekdosi/kinonika-iatria-stin-ellada-tis-krisis-i- empiria-tis-parochis-ipiresion-igias-otan-to-ethniko-sistima-igias-ipochori/. Chantzaras, Athanasios; Yfantopoulos, John (2018) “Financial Protection of Households against Health Shocks in Greece During the Economic Crisis”, Social Science & Medicine, 211, 338-351. Grigorakis, Nikolaos; Floros, Christos; Tsangari, Haritini; Tsoukatos, Evangelos (2017), “Combining Social and Private Health Insurance versus Catastrophic Out of Pocket Payments for Private Hospital Care in Greece”, International Journal of Health Economics and Management, 17(3), 261-287. Boulountza, Penny (2016), “Up to a Year on the Waiting List for Surgery”, Kathimerini Newspaper, 14 February, p. 26. EC – European Commission (2018a), “Commission Implementing Decision of 11.7.2018 on the Activation of Enhanced Surveillance for Greece”. Accessed on 30.11.2018, at https://ec.europa.eu/info/sites/info/files/economy-finance/2_en_act_part1_v7_adopted.pdf.

39 Maria Petmesidou

EC – European Commission (2018b), “The 2018 Ageing Report: Underlying Assumptions and Projection Methodologies”, European Economy Institutional Paper, 65. Accessed on 23.10.2018, at https://ec.europa.eu/info/sites/info/files/economy-finance/ip065_en.pdf. EC – European Commission (2018c), “Enhanced Surveillance Report”, European Economy Institutional Paper, 90. Accessed on 29.11.2018, at https://ec.europa.eu/info/sites/info/files/economy-finance/ip090_en.pdf. Economou, Charalambos; Kaitelidou, Daphne; Karanikolos, Marina; Maresso, Anna (2017), “Greece. Health System Review”, Health Systems in Transition, 19(5), WHO/Europe. Accessed on 20.03.2018, at http://www.euro.who.int/__data/assets/pdf_file/0006/373695/hit-greece-eng.pdf. Eurofound (2017), European Quality of Life Survey 2016: Quality of Life, Quality of Public Services, and Quality of Society. Luxembourg: Publications Office of the European Union. Accessed on 25.11.2018, at https://www.eurofound.europa.eu/sites/default/files/ef_publication/field_ef_document/ef17 33en.pdf. Global Burden of Disease Study (2016), “The burden of disease in Greece, Health Costs, Risk Factors, and Health Financing, 2000-16: An Analysis of the Global Burden of Disease Study 2018”, The Lancet, 3(8), e395-e406. Accessed on 25.08.2018, at https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30130-0/fulltext. Ifanti, Amalia; Argyriou, Andreas; Kalofonou, Foteini; Kalofonos, Haralambos (2014), “Physicians’ Brain Drain in Greece: A Perspective on the Reasons Why and How to Address It”, Health Policy, 117(2), 210-215. Independent Authority for Public Revenue (2017), “Review on the Development and Fluctuation of Public Revenue: An Account for 2017” [in Greek]. Accessed on 30.09.2018, at https://www.aade.gr/sites/default/files/2018-03/ekthesi_forolokikwn_esodwn_2017.pdf. IMF – International Monetary Fund (2018), “Greece”, IMF Country Report, No. 18/248. Accessed on 25.11.2018, at https://www.imf.org/en/Publications/CR/Issues/2018/07/31/Greece-2018-Article-IV- Consultation-and-Proposal-for-Post-Program-Monitoring-Press-Release-46138 Kaitelidou, Daphne; Katharaki, Maria; Kalogeropoulou, Maria; Economou, Charalambos; Siskou, Olga; Souliotis, Kyriakos; Tsavalias, Konstantinos; Liaropoulos, Lycourgos (2016), “The Impact of Economic Crisis to Hospital Sector and the Efficiency of Greek Public Hospitals”, European Journal of Business and Social Sciences, 4(10), 111-125. Karakolias, Stefanos; Polyzos, Nikolaos (2014), “The Newly Established Unified Healthcare Fund (EOPYY): Current Situation and Proposed Structural Changes, towards an Upgraded Model of Primary Health Care, in Greece”, Health, 6(9), 809-821. Accessed on 22.11.2017, at http://dx.doi.org/10.4236/health.2014.69103. Kingdon, John W. (1995), Agendas, Alternatives and Public Policy. New York: Harper Collins.

40 Challenges to Healthcare Reform in Crisis-Hit Greece

Laliotis, Ioannis; Ioannidis, John P.A.; Stavropoulou, Charitini (2016), “Total and Cause-specific Mortality before and after the Onset of the Greek Economic Crisis: An Interrupted Time- series Analysis”, The Lancet, 1(2), e56-e65. Liaropoulos, Lycourgos (2010), “The Health Deficit”, To Vima Newspaper, August 3 [in Greek]. Accessed on 15.07.2018, at https://www.tovima.gr/2010/08/03/opinions/to-elleimma-tis- ygeias/. Liaropoulos, Lycourgos; Siskou, Olga; Kaitelidou, Daphne; Theodorou, Mamas; Katostaras, Theofanis (2008), “Informal Payments in Public Hospitals in Greece”, Health Policy, 87(1), 72-81. Mody, Ashoka (2018), “The IMF Abetted the European Union’s Subversion of Greek Democracy”, Open Democracy, September 1. Accessed on 20.9.2018, at https://www.opendemocracy.net/can-europe-make-it/ashoka-mody/imf-abetted-european- union-s-subversion-of-greek-democracy. Petmesidou, Maria (2014), Pensions, Health and Social Care in Greece. Cologne: GVG – Gesellschaft für Versicherungswissenschaft und Gestaltung. Petmesidou, Maria (2017), “Welfare Reform in Greece: A Major Crisis, Crippling Debt Conditions and Stark Challenges ahead”, in Peter Taylor-Gooby; Benjamin Leruth; Heejung Chung (eds.), After Austerity. Welfare State Transformation in Europe after the Great Recession. Oxford: Oxford University Press,155-179. Petmesidou, Maria (forthcoming), “Health Policy and Politics”, in Kevin Featherstone; Dimitri Sotiropoulos (eds.), The Oxford Handbook of Modern Greek Politics. Oxford: Oxford University Press. Petmesidou, Maria; Glatzer, Miguel (2015), “The Crisis Imperative, Reform Dynamics and Rescaling in Greece and Portugal”, European Journal of Social Security, 17(2), 157-180. Petmesidou, Maria; Guillén, Ana (2008), “‘Southern Style’ National Health Services? Recent Reforms and Trends in Spain and Greece”, Social Policy and Administration, 42(2), 106- 124. Petmesidou, Maria; Papanastasiou, Stefanos; Pempetzoglou, Maria; Papatheodorou, Christos; Polyzoidis, Periklis (2015), Health and Long-term Care [in Greek]. Athens: INE/GSEE – Observatory on Economic and Social Developments. Accessed on 15.06.2018, at https://ineobservatory.gr/publication/igia-ke-makrochronia-frontida-stin-ellada/. Petmesidou, Maria; Pavolini, Emmanuele; Guillén, Ana (2014), “South European Healthcare Systems under Harsh Austerity: A Progress-regression Mix?”, South European Society and Politics, 19(3), 331-352. Pierson, Paul (1996), “The New Politics of the Welfare State”, World Politics, 48(2), 143-179. Romei, Valentina (2018), “In Charts: Greece’s Economy is Rebounding – But There Is far to Go”, Financial Times, August 18. Accessed on 20.9.2018, at https://www.ft.com/content/3067bf9c-8a88-11e8-bf9e-8771d5404543. Souliotis, Kyriakos; Golna, Christina; Tountas, Yannis; Siskou, Olga; Kaitelidou, Daphne; Liaropoulos, Lycourgos (2016), “Informal Payments in the Greek Health Sector amid

41 Maria Petmesidou

Financial Crisis: Old Habits Die Last”, European Journal of Health Economics, 17(2), 159- 170. Thelen, Kathleen (2004), How Institutions Evolve. Cambridge: Cambridge University Press. Tsiligianni, Ioanna; Anastasiou, Foteini; Antonopoulou, Maria; Lionis, Christos (2013), “Greek Rural GPs’ Opinions on how Financial Crisis Influences Health, Quality of Care and Health Equity”, Rural Remote Health, 13(2), 25-28. Tsiligianni, Ioanna; Papadokostakis, Polyvios; Prokopiadou, Dimitra; Stefanaki, Ioanna; Tsakountakis, Nikolaos; Lionis, Christos (2014), “Impact of the Financial Crisis on Adherence to Treatment of a Rural Population in Crete, Greece”, Quality in Primary Care, 22(5), 238-244. Wilsford, David (1994), “Path Dependency, or Why History Makes It Difficult but not Impossible to Reform Health Care Systems in a Big Way”, Journal of Public Policy, 14(3), 251-283. 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 Health Services Research, 16(309), 1-7. Accessed on 15.11.2018, at https://bmchealthservres.biomedcentral.com/track/pdf/10.1186/s12913-016-1557-5.

42 e-cadernos CES, 31, 2019: 43-67

PEDRO HESPANHA

THE IMPACT OF AUSTERITY ON THE PORTUGUESE NATIONAL HEALTH SERVICE, CITIZENS’

WELL-BEING, AND HEALTH INEQUALITIES

Abstract: This article discusses the main lines of the anti-crisis policy in Portugal, its consequences on the citizens’ well-being and health inequalities and the impasses in health reforms planned both to ensure the financial sustainability of the health system and to improve equity. Different studies reveal that health inequalities in Portugal have been consistently higher than those observed in other European countries in the last decade and continue to be closely associated with geography, income, and health literacy. In the absence of a well-structured reform program, the blind cuts on expenses prevailed, showing no consideration to their impact in very sensitive areas of medical care. The manner in which slowness, insufficiency or downgrading of services affects citizens differs according to their social condition and the way they deal with the situation. The article is illustrated with examples of how citizens, families, and civil society organizations have sought to circumvent the lack of response from public health services. Keywords: austerity, crisis, health inequalities, health reforms, National Health System.

O IMPACTO DA AUSTERIDADE NO SERVIÇO NACIONAL DE SAÚDE PORTUGUÊS, O BEM-ESTAR

DOS CIDADÃOS E AS DESIGUALDADES NA SAÚDE

Resumo: Este artigo discute as principais linhas da política anti-crise em Portugal, as suas consequências sobre o bem-estar dos cidadãos e sobre as desigualdades em saúde, bem como os impasses nas reformas em saúde planeadas para garantir a sustentabilidade financeira do sistema de saúde e melhorar a sua equidade. Diferentes estudos revelam que as desigualdades na saúde em Portugal têm sido consistentemente mais altas do que as observadas em outros países europeus na última década 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 nas despesas públicas, sem levar em consideração o impacto que esses cortes produziriam em áreas muito sensíveis dos cuidados médicos. A maneira pela qual a lentidão, a insuficiência ou a desqualificação dos serviços afeta os cidadãos difere de acordo com a respetiva condição social e com 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 serviços públicos de saúde. Palavras-chave: austeridade, crise, desigualdade em saúde, reformas na saúde, Serviço Nacional de Saúde.

43 Pedro Hespanha

1. WELFARE STATE, CRISIS AND REFORMS IN PORTUGAL In the last 15 years, social protection systems have been undermined in many countries due to the convergence of neoliberal ideas and the increasing financial and political restrictions resulting from the state’s financial crisis originated in the second half of the 1970s, deepened during the 1990s, and turned acute as from 2008 – initially only financial and soon after economic, social and political crises. Neoliberalization, which implies public provision remarketing, reversion of policies’ universalism, and shared governance of social protection, has been putting at risk the fundaments of both welfare state and welfare society. 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 in their policies to safeguard central achievements of the welfare state. Nevertheless, there is the risk that these adjustments accumulate until the point of creating a definitely neoliberal institutional framework of social welfare. The emerging hypothesis regarding the nature of neoliberalization of the more radical structural adjustment processes, such as those occurring in Southern European countries like Portugal, is that one may be observing not only a mere neoliberal adjustment, but rather a change of regime in the social protection system, as has already happened in other parts of the world that are subjected to structural adjustment programs imposed by the International Monetary Fund (IMF) and the World Bank. The historical alliance between market economy, welfare state, and democracy, which founded the modern nation-state project, appears to be breaking up at the present age of global capitalism. Nevertheless, the welfare state still has strong public support and one cannot affirm that a totally ‘privatist’ and ‘individualistic’ ideology has penetrated the values and expectations of Europeans. Actually, the state continues to be an arena of tensions between the ideas of social services privatization and the ideas that defend the public welfare provision for all citizens (Bourdieu, 1999, 2014; Wacquant, 2009). If these characteristics are verifiable in all developed welfare states, they are even more so in the Southern European welfare states that emerged in the context of the international crisis of the second half of the 1970s and where the social pacts enabled the achievement of reforms in policies of social protection, employment, and income until the emergence of the 2008 economic and financial crisis. This crisis increasingly reduced the margin of flexibility of governments that were strongly subjected to the supervision of international institutions, thus forced to limit social dialogue regarding their main characteristics: decision-making autonomy of players and valorization of contributions from each part to the negotiation (Begega and Balbona, 2015), and, later, the impositions of adjustment programs following the sovereign debt rescue.

44 The Impact of Austerity on the Portuguese NHS, Citizens’ Well-Being, and Health Inequalities Focusing on Portugal, I will start by mentioning the factors that triggered the financial crisis 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 current century, of high external debts concerning the state, the families, and the firms. The growing demand for external financing of public debt and for banking investment provoked a strong interest rate increase in the financial markets along with a rating degradation of the Portuguese sovereign debt and bank solvency. The adjustment program started in May 2011 and lasted until mid-2015. There are two aspects to be highlighted in the Portuguese case for the assessment of the anti-crisis policy: first, since 2009, before the subscription of the program, the government had started a set of measures to combat the crisis – Stability and Growth Programs I, II and III – basically consisting of public expenditure reduction; second, after the right-wing coalition government (2011), which had the responsibility to implement the adjustment program 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 by reinforcing austerity measures. The Memorandum of Understanding (MoU) subscribed by the Portuguese government comprised a set of measures specifically directed to the health sector, along with other transversal to different sectors aiming to reduce public expenditure (União Europeia et al., 2011). The analysis will focus on these measures and their negative and somehow unforeseen consequences. The immediacy and urgency imposed by the bail-out program very much centered on the control of public expenditure, fully conditioned the design and results of the adjustments and reforms. In a short period of time, a large number of measures were implemented along with a strict schedule monitored by the Troika every three months, which required from the government something that it couldn’t afford in those circumstances – time and negotiation ability (Sakellarides et al., 2014).2

2. THE BLIND CUTS AND THE RISK OF SERVICES DOWNGRADING The tight regime of austerity chosen to control public expenditure basically meant cuts in public expenditure. Using an accessible language that all people would accept, the government 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 task when

1 A consortium of creditors constituted by the European Commission (EC), the European Central Bank (ECB) and the International Monetary Fund (IMF). 2 For a better understanding of the sovereign debt crisis in Portugal and of the economic adjustment programs for the health sector imposed by the troika memorandum of understanding, see Hespanha (2017).

45 Pedro Hespanha immediate results were expected. In the beginning, “fats” were identified with current expenses (not with personnel expenses), but soon it was clear that much outsourcing labor was also affected because in state accounting the “acquisition of services” is considered as a current expense. Current expenses include activities that are instrumental to the services’ operation and therefore 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 and technical 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 as xerox copies. The drastic reduction of outsourced staff led to a ‘massive dismissal’ of workers or, in some services, the paralysis of work (Hespanha et al., 2014: 210). The economic crisis impacted directly in health expenditure. Between 2010 and 2013 the Gross domestic product (GDP) was reduced by 5.4% and the total health expenditure by 12.4% (INE, 2016). When we analyze public expenses in health since 2010 the two most striking findings are the reduction of personnel expenses (between 2010 and 2012 they were reduced by 27%) and the reduction of capital expenses (between 2010 and 2014 they were reduced by 81%) (Table 1).3

Government expenditure on health fell more than in other public sectors, as the share of health to general government spending came down from 13.8% in 2009 to 12.3% in 2015. The public share of health expenditure fell more rapidly since 2011 and 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 for health care spending (28%), well above the EU average (15%). Private VHI has been growing over the years, but still only accounts for 5% of health financing, converging with the EU average. (OECD and European Observatory, 2017: 6)

3 The data of the European Observatory on Health Systems and Policies are collected from the National Budgets (Orçamento Geral do Estado, in Portuguese) and, therefore, the numbers are a little higher (between +6,9% in 2012 and +2,5% in 2014).

46 The Impact of Austerity on the Portuguese NHS, Citizens’ Well-Being, and Health Inequalities

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

CGE* CGE CGE CGE CGE CGE CGE CGE 2010 2011 2012 2013 2014 2015 2016 2017

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

Pers. exp. / 13.2 12,7 9,3 12,4 11,8 37,7 38,7 39,9 Total exp. (%)

Purchase of goods 8 036,6 7 533,1 8,767.0 7 749,2 7 365,2 5 563,5 5 695,9 5 755,4 and services

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

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

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

Purchase of capital 94,0 99,9 78,3 21,6 20,4 163,4 116,6 110,6 goods

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.

In the absence of a structured reform program based on a hierarchy of necessities, at large it prevailed a blind application of cuts on expenses, with no attention to the impact that these cuts would produce in very sensitive areas of health care. Also, the measures for efficiency improvement were implemented without taking into account the capacities of health administration to achieve them, which resulted in many of them not reaching the expected objectives (Sakellarides et al., 2014). The great criticism to be made about the implementation of the MoU is that it did not actually lead to the implementation of any of the reforms that were necessary and expected. During the four years under the Troika’s rule, the government limited itself to presenting a draft for the state reform that was not even discussed (Governo de Portugal, 2013). The announced reforms of hospital care and primary health care may serve as an example of what should have been done and has not been. Representing 60% of the expenses of the National Health Service – NHS (Serviço Nacional de Saúde, in Portuguese), public hospitals were considered the reforms’ priority target. There should

47 Pedro Hespanha have been a reorganization of the national hospital network, which was accused of suffering from significant inefficiencies, such as the duplication of services provided in certain areas, as urgencies, maternities, oncology, and transplant services. However, a report of the Troika (EC, 2014) recognizes that, although a lot had been done, the reform of the hospital network was far from being achieved and identifies a number of causes for this: resistance in the reclassification of hospitals and reallocation or sharing of medical equipment, low staff mobility and centralization of decisions that should be made at regional level. Regarding the latter, it is obvious that the strong resistance of services and the unpopularity of the reform is, above all, an effect of the absence of participation of the institutions and their officials and professionals in the reform design and implementation processes. Moreover, the fact that professionals were experiencing an overload of work did not contribute to a favorable atmosphere. This overload resulted from the dismissal of staff with no replacement or replaced by “insufficient quantity of young unexperienced physicians who, regardless of their specialty, must work 18 hours shifts at the emergency service, instead of the previous 12 hours”, as denounced by the President of the Portuguese Medical Association (Silva, 2015; translation by the author). Similarly, the reinforcement of primary health care stipulated in the MoU was not implemented, despite the recognition of its potential contribution to the cost-efficiency of the hospital and emergency care. An important component of this type of care is provided by general practitioners or family doctors of the NHS, which are at the risk of increasing the numbers of citizens without medical assistant if new professionals are not 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 of vacancies for general and family medicine internship, and the creation of some Family Health Units (Unidade de Saúde Familiar, in Portuguese) –, there are hindrances in the daily 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 of some operational unities (OPSS, 2014: 109). 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 one hand, 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 be unacceptable due to the small amount of the mobility incentive and to the imposed mobility restrictions (five years of a mandatory period). Together with other causes, this explains the maintenance of one million Portuguese inhabitants (one and a half in every ten) without a family doctor, despite the availability of human resources in the market

48 The Impact of Austerity on the Portuguese NHS, Citizens’ Well-Being, and Health Inequalities and the increase in the number of patients per family doctor, making it impossible to manage the lists of patients waiting for consultation (Silva, 2015).

3. THE STAFF REDUCTION PRIORITY Staff reduction in public services became a government obsession, despite the awareness that the blind reduction of the number of employees would have serious social consequences in the crisis context. These reductions were achieved, to a large extent, at the expense of worsening working conditions. The reduction of health professional wages, the loss of holidays and Christmas subsidies (two extra month salaries) in 2012, the non-payment of overtime, the freezing of career promotions, and the no offer of public examinations for the recruitment of physicians and nurses led to the emigration of many unemployed professionals,4 the anticipated retirement of professionals with long careers and a considerable number of professionals moving to the private sector. In the case of physicians, there was severe criticism to the decision of not hiring young professionals, whose education lasted many years and to a large extent was financed by public resources, thus representing a serious waste of resources. This situation led to a strike of physicians in July 2012, when the Ministry of Health and the unions negotiated an agreement that included revision of wages, reduction of heavy overloads, hiring new professionals, opportunities for career progression, extending users’ lists of family doctors (from 1500 to 1900) and increased mobility of doctors within the NHS (Sakellarides et al., 2014). In spite of this, the effects of the staff reduction policy on the quality of health care services associated with other austerity policies are a matter of great concern. The same with increasing levels of burnout syndrome among health professionals, associated with the perception of poor working conditions and reduced professional experience (WHO et al., 2018: 18; Marques and Macedo, 2018). There are many examples of services that are going through processes of degradation as 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 costs reductions is concealed under the argument of greater rationalization of services or compliance with international standards, as in the cases of closing urgencies and

4 It is estimated that, since 2009, 14,780 nurses have applied for emigration documents (Rita and Saramago, 2016). According to the President of the Medical Association, “hundreds of physicians are emigrating every year and if we don’t do what is necessary to retain them it will be a great loss, in terms of investment and scientific knowledge. We are exporting brains” (Observatório da Emigração, 2015; translation by the author). Furthermore, the dynamics of medical school graduates and the retirement of medical doctors are likely to generate a surplus that may not be absorbed by the healthcare system until 2025 (Santana et al., 2014).

49 Pedro Hespanha maternities, prescription of medicines in public hospitals, and ‘implicit rationalization’ of public health services.5 The services quality degradation resulting from the reduction or freezing of human and material resources’ expenses, is one of the greatest threats to the public health system. It undermines citizens’ confidence and increases their dissatisfaction. A report from OECD reveals critical aspects in the operation of hospital services: e.g. high fatility rates within 30 days after admission for ischemic stroke cases – 10.5% against 8.5% in OECD member countries average (OECD, 2015: 29). Portugal also presented the worst performance regarding waiting time for surgeries and the rate of infections associated with care in hospitalization (approximately 11% of hospitalized patients in 2012, well above the average of 6% in the EU) (ibidem). In the same direction, another report on Portugal concludes that “in comparative terms, the universal healthcare system produces good results, although the expenses cuts have undermined inclusiveness and quality” (SGI, 2015). Yet, a study carried out by an independent Swedish organization placed the Portuguese National Health System four positions below the one occupied in 2009, mainly due to excessively long waiting time, reduction on co-payment of medicines, difficulty in the access to innovative pharmaceutical products, and a huge stagnation of the system (Björnberg, 2016). It is worthy to recall the remark made by Ramesh Mishra, a long time ago, regarding the strategy of residualization of public services followed by Margaret Thatcher’s government: “cost containment and the decline of quality of public services may be expected to lead to more private alternatives especially in times of increasing private prosperity. In other words, universality may be weakened by attrition rather than by assault” (Mishra, 1990: 37). Or, as stated by Boaventura de Sousa Santos in 2002:

many of these services that are currently “public services” have almost endless business potentialities. In order to make this happen without much social disturbance, it is necessary that the idea of public service is gradually demoralized. The most efficient strategy consists in starting from false generalizations, taking blind measures, and justifying them with populist arguments (against the “misspending of taxpayers’ money”). (Santos, 2002; translation by the author)

5 A broad description of the signs of health services downgrading and progressive inaccessibility to patients is available in the 2012 issue of Portuguese Observatory of the Health Systems (OPSS, in the Portuguese acronym).

50 The Impact of Austerity on the Portuguese NHS, Citizens’ Well-Being, and Health Inequalities

4. GOVERNMENTS’ LIMITED ROOM FOR MANEUVER This crisis increasingly reduced the room for maneuver of governments that were strongly subjected to the supervision of international institutions, thus forced to limit social dialogue regarding their main characteristics: decision-making autonomy of players and valorization of contributions from each part to the negotiation (Begega and Balbona, 2015), and, later, the impositions of adjustment programs following the sovereign debt rescue. In order to better control the implementation of the MoU, the government was forced to reverse the ongoing decentralization process of the public health system. This centralist return, not being an expressed option, was manifested by means of a set of mechanisms that limited the participation of organizations and public health services in policies’ decision-making and concentrated them at the top of the Ministry of Finances (OPSS, 2014: 23). One of these mechanisms is the “law of commitments”, in force since the beginning of 2012 to “reduce the deficit of Public Administration” and restrain “expenditure growth”. It institutes that those responsible for the accountancy in public services may not assume commitments that exceed the available funds in the short-term. The assumption of multiannual commitments, including new investment projects, reprogramming of old ones or hiring contracts, among others, must be subjected to previous authorization of the Ministry of Finances (Assembleia da República, 2012). The OPSS considers that this law had very negative effects, in particular, on the motivation and accountability of the heads of health services, already disturbed by the excessive and unnecessary bureaucratization of the process of personnel hiring and purchase of goods and services.

The short term bureaucratic barriers and the environment of uncertainty regarding the 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 taken centrally removes the efficacy, critical mass, experience, and innovation capacity to find adequate solutions. (OPSS, 2014: 34; translation by the author)

Other mechanisms promoted as well the centralist return, by centralizing the recruiting of staff for the public administration into an inter-ministerial commission (Comissão de Recrutamento e Seleção para a Administração Pública, in Portuguese); by making more difficult the celebration or the renewal of job contracts by state-owned enterprises; by grouping the Health Centers for management purposes in regional

51 Pedro Hespanha entities (Agrupamentos de Centros de Saúde, in Portuguese); by concentrating the dissemination of information in a centralized department of the Ministry for Health (Direção-Geral da Saúde, in Portuguese); and by creating limitations and constraints concerning decision-making within organizations, both in the administrative public sector and the state-owned enterprises (OPSS, 2014). In an inverse movement to that of centralizing decision-making, the government entrusts more and more the private sector, for-profit or non-profit, with the responsibility of managing health units under the argument of public expenses reduction, without any clear evidence of its truth. For José Manuel Silva, the President of the Portuguese Medical Association, there was a high increase in contracting services with the private sector and the non-profit sector. At the same time, the Ministry of Health promoted the move of physicians and other health professionals to the private sector. According to Silva (2015), the government has been promoting the destruction of the small private medicine of proximity in order to favor the large health oligopolies, by imposing on them small rules that even the state does not comply with. A particularly serious situation results from the fact that apparently positive measures meant to reduce expenditure and improve the well-being of users of the national health system are producing unexpected effects that have worsened the previous situation. It is the case of the policy of reducing the price of drugs recommended by the Troika and thoroughly followed by the Portuguese government. This policy has several addressees: starting with the pharmaceutical industry and then the drugstore sector. The government established several agreements with the pharmaceutical industry in order to lower the prices of medicines and, in this way, to reduce public expenditure and to fix a new tax on the sales of pharmaceutical products in the modality of withholding tax. The price reduction was well-succeeded but generated an unexpected problem: some drugs became internationally competitive and the wholesalers preferred to export them instead of supplying the national market as it was supposed. According to the Executive Director of Health Cluster Portugal, “these results have been produced by the ability of firms that, due to the prices being internally pressed down, searched for new markets” (Alves, 2016; translation by the author). Regarding drugstores, it was verified that the reduction of the market margin of medicines also reduced their capacity to maintain stocks of the usual ones, resulting in supply 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 in 2014, in at least one wholesaler (i.e., over 60% of the totality of drugstores in Portugal and 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 amount

52 The Impact of Austerity on the Portuguese NHS, Citizens’ Well-Being, and Health Inequalities of 27 million euros for delayed payment, in pre-litigious phase (OPSS, 2015: 74). A study carried out in 2012 concluded that approximately 88% of the drugstores reduced the minimum stock of most medicines, 86.5% reduced the average amount of purchased packages, and 92% reported almost daily difficulties to obtain medicines from wholesalers (OPSS, 2013: 63). The direct effect of the reduction of margins6 in combination with the indirect effect of successive reductions of prices of medicines,7 and the main remuneration source of drugstores (Martins and Queirós, 2015) resulted in a negative impact, especially to drugstores and wholesalers particularly affected by the double reduction in their remuneration. Between 2011 and 2014, the market margin of medicines was reduced in approximately 322.8 million euros, far above the 50 million euros established by Troika’s MoU. In this period, many drugstores were closed (Infarmed, 2015) and the sector registered an increase of 177% in the number of drugstores with insolvency processes and 79.4% in the number of drugstores with pledges.

5. INCREASING INEQUALITIES IN THE ACCESS TO NHS In the European context, Portugal appears as one of the countries in which the institutionalization of social rights and the responses of the state with the adequate means for coherent social policy occurred later and were more problematic. This fact is related to historical circumstances that influenced the evolution of Portuguese society throughout the 20th century, mainly in its second half. First, the persistence of a dictatorial regime until the beginning of the 1970s, which delayed the modernization of the administrative apparatus and the establishment of citizenship rights. Second, a clear delay in the processes of industrialization, urbanization, and expansion of service sector compared to what occurred in the northern European countries. The so-called Estado Novo, ruled for nearly half a century by Salazar, adopted a model of social regulation hostile to the development of consistent social policies. It staked itself, rather, on a conservative ideology supported by the rural condition of large part of the population, which permitted the maintenance of social support based on family and community solidarity and on weak expectations in relation to consumption and quality of life. It was only after the establishment of the democratic regime in 1974 that the first systematic programs, aiming at the construction of a welfare state were developed. This was reflected in the growth of public expenses on welfare. However, this takeoff occurred

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).

53 Pedro Hespanha during an international economic crisis, exactly when the more developed welfare states had begun to face the need of adopting more restrictive postures. As a consequence, the expansionism felt since the change of regime was followed by a phase of budget restraint after 1982, which prevented Portugal from approaching the model of state producing welfare which characterized many other European countries. However, the frailties of the Portuguese “semi-welfare-state” (Santos, 1993) have been partially 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 the Portuguese society (Hespanha et al., 1997: 173). Anyway, Portugal created its NHS in 1979, based on universalism, generality, and free of charge (fully funded by taxes). Since its beginning the NHS faced many obstacles and limitations: right-wing parties, the Portuguese Medical Association and the biggest health industry corporations joined together to constrain its development; the weakness of public resources for investment, including some areas of specialized doctors, forced governments to make agreements with private health clinics, laboratories, and diagnostic units in order to ensure universalism. Later on, new hospitals were created under public- private partnerships and private hospitals were committed to assisting patients included in long waiting lists of NHS hospitals. Instead of growing and gaining autonomy in the provision of services, as expected, the Portuguese NHS has become increasingly dependent on private provision (Carapinheiro, 2006; Campos, 2011, 2014; Carapinheiro et al., 2013). The austerity policies imposed by the financial assistance program of the Troika since May 2011 and embraced by the right-wing governments between June 2011 and November 2015 have greatly aggravated this picture as discussed previously. This austerity rule has not well defined outlines which may lead to quite different interpretations. To simplify, it can be said that it refers to a set of economic and social policy options by which governments aim to halt or reduce public expenditure, and that these options allow “altering the state’s redistributive policy and the expenditure related to the functioning of the economy and social reproduction” (Ferreira, 2014: 117; translation by the author). The MoU signed in May 2011 by the Portuguese Government consisted of a shock therapy for the recovering of the fiscal crisis that included a large array of measures with a potential negative impact on social equity. First, to ensure a fiscal consolidation over the medium term by containing expenditure growth, reducing transfers from the state to public bodies and other entities; second, to decrease the staff numbers of central, regional and local administration, reducing the wages of civil servants, freezing new

54 The Impact of Austerity on the Portuguese NHS, Citizens’ Well-Being, and Health Inequalities admissions as well as constraining their promotions; and to promote flexibility, adaptability and mobility of human resources across the administration; third, to reduce social benefits, pensions and subsidies; fourth, to cut on expenses of public bodies and state-owned enterprises and to reduce capital expenditure; fifth, to reduce corporate tax deductions and special regimes, to reduce the personal income tax benefits and deductions; sixth, to increase VAT revenues and some special taxes; seventh, to reduce the degree of subsidization of public enterprises; eighth, to privatize, total or partially, the biggest public enterprises. In the particular field of health policies, the Memorandum includes the following measures: first, the strict control of costs in health sector with substantial reduction in operational costs, in spending on overtime compensation, and in costs for patient transportation; second, the increase of overall NHS user charges or moderating fees (taxas moderadoras)8 in parallel to a stricter design of means-testing criteria for exempting taxes; third, the substantial cut in tax allowances for healthcare, including private insurance (by two thirds overall); fourth, the reduction of the budgetary cost of health-benefits schemes for civil servants; fifth, the reduction of the reimbursement of medicines for patients. The governmental coalition that ruled during the Troika period used austerity to enforce a project of state political reform of a neoliberal imprint, which under the argument that there is no alternative to austerity as a response to the crisis, restrained expenditure, privatized state-owned enterprises and used labour cost as an adjustment variable of the deficit. In result, political institutions became weak, inefficient and unqualified, citizens became dependent, poor, and deprived, and exceptional rights that do not respect the most basic principles of the rule of law and of democracy (Ferreira, 2014: 438). Damages caused by austerity to the Portuguese economy and society manifested in many ways. From the beginning, deep recession occurred with serious implications for the future, not only due to investment halt and sovereign debt increase but mainly through social consequences: employment destruction and unemployment increase; precariousness, especially, of the younger segments of the economically active population; 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 weaker members of society and therefore it could not be successful (Caritas Europa, 2013: 51).

8 Before this increase, moderating fees represented 0.74% of the NHS total revenue in 2010 and 0.95% in 2011. In 2012, they accounted for 1.7% and in 2015 about 2.0% (WHO, 2018: 27).

55 Pedro Hespanha The social impact of austerity felt unequally on families and individuals. According to a study published by the European Commission (Avram et al., 2013), among the nine EU countries with larger budgetary deficits after the financial crisis at the end of the first half of the 2000s and the subsequent economic recession (Estonia, Greece, Spain, Italy, Latvia, Lithuania, Portugal, Romania and United Kingdom), Portugal, Lithuania and Estonia are the only countries where austerity measures imposed heavier financial burden on the poor than on the rich. In the period from 2009 to June 2012, Portugal underwent 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 a synthesis,

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

In order to analyze the consequences of crisis and austerity on inequalities, we may consider different dimensions: access to health care, increase in families’ out-of-pocket health spending, reduction in public healthcare investment (Serapioni, 2017). 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 and resources) and outlines the different causes of inequalities and the policy responses. It compares data from 2009 to 2013 and concludes that the financial, economic and social crisis “is threatening to undermine existing policies, and may negatively affect health inequalities” (ibidem: ix); and adverts to the fact that “inequalities in health cannot be reduced by the health sector alone – they require action on all the social determinants of health” (ibidem). Thus, “most policies with explicit aims to reduce health inequalities focus on ‘vulnerable groups’ such as immigrants, ethnic minorities, early school leavers, people from lower socio-economic groups or unemployed or homeless people” (ibidem). We take these general traces common to the member states of the EU to inspire our analysis of the Portuguese case. The annual reports of the OPSS created in 2000 by a network of researchers and academic institutions are a good source of information for

9 The estimates of the austerity weight on the distribution model largely depends on the analytical 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.

56 The Impact of Austerity on the Portuguese NHS, Citizens’ Well-Being, and Health Inequalities analyzing the course of health inequalities in Portugal, but there are other recent studies using other data and methodologies that also shed light on the same subject, as we will see later. The OPSS Report for 2015 (OPSS, 2015), the first year after the end of the external intervention, used the access to health care as its central theme. Health care accessibility is guaranteed to every citizen, “regardless of their economic condition”, by the Portuguese Republic Constitution (art. 64, no. 3, al. a). According to the OPSS report for 2015 the crisis has interfered with access to health care, whether considered the dimensions associated with supply (human resources in health, access to emergency services, access to consultations, and availability of beds in hospitals) or those associated with demand (socioeconomic conditions of citizens, out-of-pocket health expenses, and unmet health needs). The OPSS report for 2016 (OPSS, 2016) devotes a whole chapter to the theme of social inequalities in health. It began by stating three reasons why health inequalities related to social and economic factors are a cause for concern: first, inequalities in health are a matter 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 has revealed that health inequalities in Portugal have been consistently higher than those observed in other European countries in the last decade and continue to be closely associated with socioeconomic factors (income, education, gender, age – children and elderly).10 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 experienced disadvantages regarding three health indicators (poor or very poor self-reported health, the presence of at least one chronic disease, and the presence of functional limitations). In particular, inequality is very high in reported ill-health, and in 2014 uneducated people have a risk of being six times poorer than those with more education (secondary education or more). For the same indicator, inequality seems to have 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 resulting from the onset of the crisis and the implementation of austerity measures, respectively. The OPSS report for 2017, the first after the governmental change that reversed austerity policies since 2016, focused on equity in health care, assuming that equity

10 Main statistical sources used: The National Health Surveys (Inquérito Nacional de Saúde, in Portuguese) of 2005/2006 and 2014, the European Health, Aging and Retirement Survey (SHARE), and the EU Statistics on Income and Living Conditions (SILC).

57 Pedro Hespanha means that care is distributed according to the needs and not to the ability to pay or to the socioeconomic condition (OPSS, 2017: 73). The assessment of equity in the access to health care has been measured by: i) the probability of having unmet needs for four dimensions of care (medical appointments or treatments, dental care, purchase of prescribed drugs, and mental health appointments or treatments); ii) the income category (in quintiles). There is a strong probability of reporting unmet needs in all income categories, but this probability is quite unequally distributed in the cases of dental appointments (from 9% in the richest to 53% in the poorest) and mental health treatments (from 9% in the richest to 48% in the poorest). Even for medical appointments or treatments in general, access barriers range from 4% to 19%. Regarding waiting times, people in the highest income quintile have a significantly lower probability of waiting for a consultation, as compared to people in the lowest income (ibidem: 77).11 A recent academic study (Campos-Matos et al., 2017) followed the same objective using EU-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 explanatory variables. The proportion of individuals who had limitations was calculated for each year in the overall sample, within each income tercile, and stratified by age groups. A complex model of analysis allowed to observe that the proportion of individuals with limitations (mostly in daily activities), was stable at around 30% until 2011, when it increased to 43%, and then increased again in 2014 to 47% (ibidem: 2); however, health inequalities seem to have decreased over the same period driven by an increase in limitations in active people due to mechanisms such as migration trends (based on the ‘healthy migrant effect’) and socio-economic groups’ different ability to adapt to changing circumstances (ibidem: 5). Recognizing that these findings may be limited by the database design, the authors advocate “a more detailed exploration of these changes in the determinants of health, perhaps using longitudinal data, in order to capture trajectories rather than compositional changes within socioeconomic groups” (ibidem).

11 According to the Eurofound European Quality of Life Survey 2016 a delay in getting an appointment was reported as being ‘very difficult’ for 18% of respondents in 2016 in Portugal (Eurofound, 2017: 53).

58 The Impact of Austerity on the Portuguese NHS, Citizens’ Well-Being, and Health Inequalities

6. CITIZENS’ RESISTANCE STRATEGIES TOWARDS CRISIS AND AUSTERITY The manner in which insufficiency, downgrading or decreasing of services affect citizens differs extensively according to a large array of variables, the same way as dealing with this situation differs. Systematic and comprehensive research on citizens’ behavior is needed, which is hindered by the policy of public services opacity, on the one hand, and by the very unequal and irregular quality of data collection, on the other hand. It is important to stress that the effects of the reforms introduced in various domains of the health system should have been previously evaluated not only regarding their benefits for public management but also the disadvantages that they could bring to users, as has already been mentioned. For those citizens who saw the reduction of income and social support to which they had access, and also the aggravation of their living expenses, a common attitude is the reduction of health care demand such as consultations, exams, medicines, etc. Official data confirm the decrease of the number of consultations since 2011 and particularly the high absenteeism to mental health consultations because patients cannot afford to pay for transport costs (OPSS, 2015: 140). Regarding the purchase of prescribed medicines, there is evidence that many patients do not buy on a regular basis medicines associated to certain diseases: chronicle diseases, high blood pressure and hypercholesterolemia, depression, etc. (Sakellarides et al., 2014). The reduction of the exemptions on moderating fees, the duplication of the amount of these fees,12 and the extension of the moderating fees to other services,13 along with the increase of the delay to access healthcare due to the shortage of professionals, have further aggravated the situation, namely for those patients who cannot afford to use the private sector. However, there is evidence that those who can afford it shift to the private sector, subscribe to private health insurance (already covering 20% of the population in 2011), or press the public system to respond as expected. Some cases of this pressure were much publicized, as the reaction against the rationing of expensive medicaments. In February 2015 a hepatitis C patient protested at Parliament, face to face with the Minister of Health, against the decision to prevent the access to an innovative treatment (with a high cure rate) based on the high cost of the treatment. As a result, the

12 This revision of the moderating fees regime raised several questions: a) inequity of the duplication of fees amount when a severe economic and social crisis was underway; b) an assistance logic and a stigmatization risk behind the limitation of access to moderating fees exemption only to those who prove not to have the required means; c) very high costs to implement a control system for requests of fees exemption; d) reduced impact on health budget from the rise of moderating fees; and e) the fact that the moderating fees fall on the delivery of health services not chosen by users, but rather those prescribed by the doctors (Sakellarides et al., 2014). 13 Services of nursing, vaccination not included in the national vaccination plan, radiologic exams, and therapeutics in the scope of urgency services.

59 Pedro Hespanha government was forced to liberate the access to that medication for all patients in the same situation. But there are other alternatives. Citizens are not always isolated in the resolution of problems generated from or aggravated by austerity policies. This crisis also raises the emergence of answers within civil society, as for example mutual aid for the care of dependent persons, informal assistance to children, sharing of private transportation or housing, medication bank, etc. The origin of such responses is very diverse: spontaneous emergence in proximity contexts; insertion in a social and solidarity economy logic; philanthropic or social volunteering inspiration (Laville, 2005, 2011; Laville and Jané, 2009; Hespanha and Santos, 2016). Therefore, it is important to identify where the responses originate from and learn the different aspects that allow us to evaluate their efficacy: the way in which the answers arise; their more or less formal and organized condition; the individualistic, particularistic or solidarity philosophy that inspires them; the type of solidarity that feeds them – to make it simple: paternalistic or democratic, vertical or horizontal –; its sphere of action more or less enlarged and integrated; the consistency and durability of these answers; their innovative and transformative character; and the institutional recognition of the answers.

7. IN DEFENSE OF THE PUBLIC HEALTH SERVICES Several years of a strict policy of austerity, lack of investment and neglect of work conditions of the health professionals discredited and weakened the services and may have produced a strong negative impact on the people affected by the cuts and the shortage of services. The degradation of quality in health services resulting from the reduction or freezing of wages and capital investment is one of the great threats to the Portuguese NHS. It undermines citizens’ confidence, increases their dissatisfaction14 and exacerbates the current inequalities in accessing health care. However, the damages caused by this policy will take some time to repair and this cannot be achieved without significant investment in human resources and infrastructure. Since 2016, a new government essayed a policy of reversing the main austerity measures by recovering the citizens’ lost income and giving priority to the reversal of salaries, social benefits, and exemptions. But it lacks a steady policy of investment in human resources and infrastructure. “Although most of the wage cuts introduced in 2012 are currently being reversed, the payment to health care workers in the NHS, particularly physicians, is lower

14 More than half of the respondents in a study on the satisfaction of the users of the Portuguese health system feel that public health services need major changes/adjustments (38.2%) or to be completely restructured (15%) (DGS, 2015).

60 The Impact of Austerity on the Portuguese NHS, Citizens’ Well-Being, and Health Inequalities than in the private sector” (Simões et al., 2017). The promise to create 100 new Family Health Units is already consummated and represents an important investment in order to expand and improve the Primary Health Care network and allow the allocation of family doctors to approximately more 500 thousand people (XXI Governo Constitucional, 2015: 97). An increase in hiring health professionals to compensate for staff outflows caused by austerity and the reduction of the working week from 40 to 35 hours, has been successfully accomplished. In contrast, the recovery of the pre-crisis levels of investment in hospitals has failed, despite the statement by the Minister of Health, Marta Temido, that hospitals of the NHS will benefit, in the next three years, of 500 million euros of equipment investment (O Jornal Económico com Lusa, 2018). However, the real challenge to the government consists in making the needed investment with public funding15 and at the same time maintaining financial sustainability, through increasing efficiency in NHS health units (Simões et al., 2017: 171). The combined analysis of the evolution and impact of the austerity on social policies with the way in which Portuguese society is suffering the impact of the crisis reveals a huge lack of legitimacy of the austerity measures, regarding the values and legitimate expectations of social welfare in a modern European society based on the principles of political and social citizenship. At the same time, these measures are contributing to the loss of social capital, generating the risk of destroying the society’s fundaments. Whatever the circumstances are, it is important to sustain that the reform of NHS cannot abandon the essential objectives to minimize inequalities, protect the more vulnerable persons, and improve the well-being of all citizens. There are still many obstacles – possibly even more than in the past – for the improvement of public services, and one of them, very important, is the bureaucratic, authoritarian and clientelist nature of public administration, which the democratic political system intended to transform, but was not able or did not want to. Lately one observes the reinforcement of these tendencies and the increasing opacity of the criteria of public administration management, thus hampering the access to information on the austerity impacts.

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. Recent reports from the Court of Auditors have concluded, first, that “there is no evidence to confirm that the option for the PPP model generates added value compared to the traditional contracting model” (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 has not been subordinated to the needs of the population's health services, leading to increased lists and waiting times for consultations and surgeries” (Tribunal de Contas, 2016: 3; translation by the author). This debate rebound recently in the Parliament when the Government submitted a project 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 health care and promoted the development of the private health sector in competition with the public sector (Base 2, al. f).

61 Pedro Hespanha The NHS becomes essential in a context of crisis and the consequences of its degradation 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 is made, largely, through requesting the ability of health services to adjust to the new realities, making good use of the responses that society has invented – such as proximity services, health in the community, informal care –, creating closer bonds with territories, and giving more attention to the needs of the community at each moment.

PEDRO HESPANHA Faculdade de Economia da Universidade de Coimbra | Centro de Estudos Sociais da Universidade de Coimbra Avenida Dr. Dias da Silva 165, 3004-512 Coimbra, Portugal Contact: [email protected]

Received on 25.01.2019 Accepted for publication on 21.05.2019

REFERENCES Alves, Virginia (2016), “As exportações do sector da saúde cresceram 8% em 2012”, Dinheiro Vivo, June 2. Accessed on 30.10.2018, at https://www.dinheirovivo.pt/economia/as- exportacoes-do-sector-da-saude-cresceram-8-em-2012/. Avram, Silvia; Figari, Francesco; Leventi, Chrysa; Levy, Horacio; Navicke, Jekaterina; Matsaganis, Manos; Militaru, Eva; Paulus, Alari; Rastrigina, Olga; Holly Sutherland (2013), “The Distributional Effects of Fiscal Consolidation in Nine EU Countries”, EUROMOD – Working Paper Series, EM 2/13. Assembleia da República (2012), Lei n.º 8/2012 de 21 de fevereiro. Diário da República. Accessed on 12.09.2018, at http://www.pgdlisboa.pt/leis/lei_mostra_articulado.php?nid=2273&tabela=leis. Begega, Sergio; Balbona, David (2015), “Crisis económica y deterioro de los pactos sociales en el sur de Europa: Los casos de España y Portugal”, Revista Internacional de Sociología, 73(2). DOI: 10.3989/ris.2014.03.17 Björnberg, Arne (2016), “Euro Health Consumer Index 2015: Report”, Health Consumer Powerhouse. Accessed on 30.10.2018, at https://healthpowerhouse.com/media/EHCI- 2015/EHCI-2015-report.pdf. Bourdieu, Pierre (1999), “The Abdication of the State in the Weight of the World: Social Suﬀering in Contemporary Society”, in Pierre Bourdieu et al., The Weight of the World: Social Suffering in Contemporary Society. Cambridge: Polity Press, 181-188. Translation by Priscilla Parkhurst et al. [orig. 1993].

62 The Impact of Austerity on the Portuguese NHS, Citizens’ Well-Being, and Health Inequalities

Bourdieu, Pierre (2014), Sobre o Estado. São Paulo: Companhia das Letras. Campos, António Correia de; Simões, Jorge (2011), O percurso da saúde: Portugal na Europa. Coimbra: Edições Almedina. Campos, António Correia de; Simões, Jorge (eds.) (2014), 40 anos de Abril na saúde. Coimbra: Edições Almedina. Campos-Matos, Inês; Russo, Giuliano; Gonçalves, Luzia (2017), “Shifting Determinants of Health Inequalities in Unstable Times: Portugal as a Case Study”, European Journal of Public Health, 28(1), 4-9. Carapinheiro, Graça (2006), “A saúde enquanto matéria política”, in Graça Carapinheiro (ed.), Sociologia da saúde. Estudos e perspectivas. Coimbra: Pé de Página, 137-164. Carapinheiro, Graça; Serra, Helena; Correia, Tiago (2013), “Estado, medicina e políticas em Portugal”, in Fátima Alves (ed.), Saúde, medicina e sociedade – Uma visão sociológica. Lisboa: Pactor, 49-74. Caritas Europa (2013), The Impact of European Crisis: A Study of the Impact of the Crisis and Austerity on People, with a Special Focus on Greece, Ireland, Italy, Portugal and Spain. Brussels: Caritas Europa. Costa, Ana; Caldas, José Castro (2014), “A União Europeia e Portugal entre os resgates bancários e a austeridade”, in José Reis (ed.), A economia política do retrocesso: crise, causas e objetivos. Coimbra: CES/Almedina, 87-126. DGS – Direção-Geral de Saúde (2015), Estudo de satisfação dos utentes do sistema de saúde português. Lisboa: Direção-Geral de Saúde. Accessed on 12.10.2018, at https://www.dgs.pt/documentos-e-publicacoes/estudo-de-satisfacao-dos-utentes-do- sistema-de-saude-portugues-2015-pdf.aspx. EC – European Commission (2013), Health Inequalities in the EU — Final Report of a Consortium. Consortium Lead: Sir Michael Marmot. Brussels: Directorate-General for Health and Consumers. Accessed on 10.09.2018, at https://ec.europa.eu/health/sites/health/files/social_determinants/docs/healthinequalitiesin eu_2013_en.pdf. EC – European Commission (2014), “The Economic Adjustment Programme for Portugal, 2011- 2014”, Occasional Papers, 202. Brussels: Directorate-General for Economic and Financial Affairs. Eurofound – European Foundation for the Improvement of Living and Working Conditions (2012), Third European Quality of Life Survey: Quality of Life in Europe: Impacts of the Crisis. Luxembourg: Publications Office of the European Union. Eurofound – European Foundation for the Improvement of Living and Working Conditions (2017), European Quality of Life Survey 2016: Quality of Life, Quality of Public Services, and Quality of Society. Luxembourg: Publications Office of the European Union. Ferreira, António Casimiro (2014), Política e sociedade: teoria social em tempo de austeridade. Porto: Vida Económica.

63 Pedro Hespanha

Governo de Portugal (2013), “Um Estado melhor: proposta do Governo, aprovada no CM de 30 de outubro de 2013”. Lisboa: Presidência do Conselho de Ministros. Accessed on 12.09.2018, at https://www.dn.pt/DNMultimedia/DOCS+PDFS/EstadoMelhor%2030%2010%20-%20um- estado-melhor7856bba1.pdf. Hauban, Harald; Coucheir, Michael; Spooren, Jan; McAnaney, Donal; Delfosse, Claude (2012), Assessing the Impact of European Governments’ Austerity Plans on the Rights of People with Disabilities. European Report. European Foundation Centre. Accessed on 09.06.2018, at http://www.enil.eu/wp-content/uploads/2012/12/Austerity-European-Report_FINAL.pdf. Hespanha, Pedro (2017), “As reformas dos sistemas de saúde na Europa do Sul: crises e alternativas”, in Paulo Henrique Rodrigues; Isabela Santos (eds.), Políticas e riscos sociais no Brasil e na Europa: convergências e divergências. Rio de Janeiro: HUCITEC Editora, 81-110. Hespanha, Pedro; Ferreira, Claudino; Portugal, Sílvia (1997), “Welfare Society and Welfare State”, in Maurice Roche; Rik van Berkel (eds.), European Citizenship and Social Exclusion. Aldershot: Ashgate, 169-183. Hespanha, Pedro; Ferreira, Sílvia; Pacheco, Vanda (2014), “O Estado social, crise e reformas”, in José Reis (ed.), A economia política do retrocesso: crise, causas e objetivos. Coimbra: CES/Almedina, 189-281. Hespanha, Pedro; Santos, Luciane Lucas dos (2016), “O nome e a coisa. Sobre a invisibilidade e a ausência de reconhecimento institucional da Economia Solidária em Portugal”, Revista de Economia Solidária, 9, 22-68. INE – Instituto Nacional de Estatística (2016), Statistics Portugal Database. Available at https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_main. Infarmed – Autoridade Nacional do Medicamento e Produtos de Saúde, I. P. (2015), Estatística do medicamento 2013. Lisboa: Ministério da Saúde. Accessed on 02.09.2018, at http://www.infarmed.pt/documents/15786/1229727/Estat%C3%ADstica+do+Medicament o+2013/031fe3d4-8f86-45f7-adc9-55bc1ca2079e?version=1.1. Jessop, Bob (2013), “Putting Neoliberalism in Its Time and Place: a Response to the Debate”, Social Anthropology, 21(1), 65-74. Laparra, Miguel; Pérez Eransus, Begoña (eds.) (2012), Crisis y fractura social en Europa. Causas y efectos en España, Colección Estudios Sociales, no. 35. Barcelona: Obra Social ‘La Caixa’. Laville, Jean-Louis (2005), Sociologie des services: entre marché et solidarité. Ramonville: Érès. Laville, Jean-Louis (2011), Agir à gauche: L’économie sociale et solidaire. Paris: Desclée de Brouwer. Laville, Jean-Louis; Jané, Jordi (2009), Crisis capitalista y economia solidaria: una economia que emerge como alternativa real. Barcelona: Icaria.

64 The Impact of Austerity on the Portuguese NHS, Citizens’ Well-Being, and Health Inequalities

Marques, Ana Paula; Macedo, Ana Paula (2018), “Políticas de Saúde do Sul da Europa e desregulação das relações de trabalho: um olhar sobre Portugal”, Ciência & Saúde Coletiva, 23(7), 2253-2263. Martins, Lurdes Castro; Queirós, Sónia (2015), “Competition among Pharmacies and the Typology of Services Delivered: The Portuguese Case”, Health Policy, 119(5), 640-647. Mishra, Ramesh (1990), The Welfare State in Capitalist Society. Hempstead: Harvester Wheatsheaf. O Jornal Económico com Lusa (2018) “Hospitais precisam de 500 milhões em equipamentos nos próximos três anos, diz ministra”, O Jornal Económico, December 14. Accessed on 14.12.2018, at https://jornaleconomico.sapo.pt/noticias/hospitais-precisam-de-500- milhoes-em-equipamentos-nos-proximos-tres-anos-diz-ministra-389499. Observatório da Emigração (2015), “Médicos estão a emigrar às centenas”, October 22. Accessed on 23.10.2018, at http://observatorioemigracao.pt/np4/4623.html. OECD (2015), Reviews of Health Care Quality: Portugal. Paris: OECD Publishing. OECD; European Observatory on Health Systems and Policies (2017), State of Health in the EU – Portugal: Country Health Profile 2017. Paris: OECD Publishing. Accessed on 10.09.2018, at https://www.oecd-ilibrary.org/docserver/9789264283527- en.pdf?expires=1545399351&id=id&accname=guest&checksum=D125AE893B4628A0D B7AFA31CC69AEEF. OPSS – Observatório Português dos Sistemas de Saúde (2013), Duas faces da saúde: relatório de primavera 2013, Observatório da Saúde Collection, no. 10. Coimbra: Mar da Palavra. Accessed on 13.10.2018, at http://www.uc.pt/org/ceisuc/Documentos/rp/rp_2013.pdf. OPSS – Observatório Português dos Sistemas de Saúde (2014), Saúde síndroma de negação: relatório de primavera 2014. Coimbra: OPSS. Accessed on 13.10.2018, at https://justnews.pt/documentos/file/Relatorio%20Primavera%202014%20- %2028junho1.pdf. OPSS – Observatório Português dos Sistemas de Saúde (2015), Acesso aos cuidados de saúde. Um direito em risco? Relatório de primavera 2015. Coimbra: OPSS. Accessed on 13.10.2018, at http://www.apdh.pt/sites/apdh.pt/files/Relatorio_Primavera_2015_VF.pdf. OPSS – Observatório Português dos Sistemas de Saúde (2016), Saúde: procuram-se novos caminhos. Relatório de primavera 2016. Coimbra: OPSS. Accessed on 13.10.2018, at http://opss.pt/wp-content/uploads/2018/06/Relatorio_Primavera_2016_1.pdf. OPSS – Observatório Português dos Sistemas de Saúde (2017), Viver tempos incertos: sustentabilidade e equidade na saúde. Relatório de primavera 2017. Coimbra: OPSS. Accessed on 13.10.2018, at http://opss.pt/wp- content/uploads/2018/06/Relatorio_Primavera_2017.pdf. OXFAM – Oxford Committee for Famine Relief (2013), “A Cautionary Tale: The True Cost of Austerity and Inequality in Europe”, OXFAM Briefing Paper, 174. Accessed on 06.06.2016, at https://www-cdn.oxfam.org/s3fs-public/file_attachments/bp174-cautionary-tale- austerity-inequality-europe-120913-en_1_1.pdf.

65 Pedro Hespanha

Paoletti, Isabella; Carvalho, Maria Irene de (2012), “Ageing, Poverty and Social Services in Portugal: The Importance of Quality Services”, Indian Journal of Gerontology, 26(3), 396- 413. Rita, Cristina; Saramago, João (2016), “14 mil enfermeiros saíram em 7 anos”, Correio da Manhã, January 31. Accessed on 06.06.2016, at https://www.cmjornal.pt/portugal/detalhe/14_mil_enfermeiros_sairam_em_7_anos. Sakellarides, Constantino; Castelo-Branco, Luis; Barbosa, Patrícia; Azevedo, Helda (2014), The Impact of the Financial Crisis on the Health System and Health in Portugal. Copenhagen: WHO Europe/European Observatory on Health Systems and Policies. Santana, Paula; Peixoto, Helena; Duarte, Nuno (2014), “Demografia médica em Portugal: análise prospectiva”, Acta Médica Portuguesa, 27(2), 246-251. 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 on 30.10.2017, 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 of Southern Europe”, Cadernos de Saúde Pública, 33(9). DOI: 10.1590/0102-311x00170116 SGI – Sustainable Governance Indicators (2015), “Portugal: Social Policies”. Accessed on 30.10.2017, at http://www.sgi-network.org/2015/Portugal/Social_Policies. Silva, José Manuel (2015), “O necessário e resumido balanço de quatro anos de Ministério da Saúde. Olhar o passado a pensar no futuro”, Revista da Ordem dos Médicos, 162, 5-11. Silva, Luisa; Augusto, Amélia; Backstrom, Barbara; Alves, Fátima (2013) “Desigualdades sociais e saúde”, in Fátima Alves (ed.), Saúde, medicina e sociedade: uma visão sociológica. Lisboa: Pactor, 25-45. Simões, Jorge de Almeida; Augusto, Gonçalo Figueiredo; Fronteira, Inês; Hernández-Quevedo, Cristina (2017), “Portugal: Health System Review”, Health Systems in Transition, 19(2). Tribunal de Contas (2013), “Encargos do Estado com PPP na Saúde.”, Relatório n.º 18/2013 – 2.ª Secção, volume I. Lisboa: Tribunal de Contas. Accessed on 10.09.2018, at https://www.tcontas.pt/pt/actos/rel_auditoria/2013/2s/audit-dgtc-rel018-2013-2s.pdf. Tribunal de Contas (2015), “Auditoria à execução do contrato de gestão do Hospital de Loures”, Relatório n.º 19/2015 – 2.ª Secção, volume I. Lisboa: Tribunal de Contas. Accessed on 10.09.2018, at http://www.tcontas.pt/pt/actos/rel_auditoria/2015/2s/audit-dgtc-rel019- 2015-2s.PDF. Tribunal de Contas (2016), “Auditoria à execução do contrato de gestão do Hospital de Braga em parceria público-privada (PPP)”, Relatório n.º 24/2016 – 2.ª Secção, volume I. Lisboa: Tribunal de Contas. Accessed on 10.09.2018, at https://www.tcontas.pt/pt/actos/rel_auditoria/2016/2s/rel024-2016-2s.pdf.

66 The Impact of Austerity on the Portuguese NHS, Citizens’ Well-Being, and Health Inequalities

União Europeia; Fundo Monetário Internacional; Banco Central Europeu (2011), “Memorando de entendimento 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 Health Systems and Policies (2018), Health System Review: Portugal. Phase 1 Final Report. Accessed on 23.10.2018, 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 on 07.11.2018, at https://www.portugal.gov.pt/ficheiros-geral/programa-do- governo-pdf.aspx.

67 e-cadernos CES, 31, 2019: 68-92

JUAN ANTONIO CÓRDOBA-DOÑA, ANTONIO ESCOLAR-PUJOLAR

THE LASTING EFFECTS OF A “RELENTLESS CRISIS”: THE GREAT RECESSION AND HEALTH

INEQUALITIES IN SPAIN

Abstract: Spain is generally regarded as one of the European countries most affected by the Great Recession starting in 2008 and subsequent restrictive policies. In the first part of this paper we attempt to understand the impacts of the crisis on the welfare state that have led to health inequalities, with a special emphasis on the history of the Spanish National Health System from mid-twentieth century onwards. We also examine citizens’ responses to austerity measures within the health system, highlighting the role of the “white tides” movement. In the second part of the paper, we provide a selective review of the main findings on the effects of the Great Recession in the country, focusing particularly on its outcomes on mental health and on inequalities in health and healthcare use. We conclude that key policies need to be directed towards “the causes of the causes” of health inequalities, a complicated challenge in the current phase of capitalism. Keywords: austerity measures, economic crisis, health inequalities, mental health, socioeconomic factors, Spain.

OS EFEITOS PERMANENTES DE UMA “CRISE INFINDÁVEL”: A GRANDE RECESSÃO E AS

DESIGUALDADES NA SAÚDE EM ESPANHA

Resumo: A Espanha é geralmente vista como um dos países europeus mais afetados pela Grande Recessão e as subsequentes políticas restritivas. Neste artigo, tentamos, em primeiro lugar, compreender os impactos 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 do século passado. Também analisamos as reações dos cidadãos às medidas de austeridade no sistema de saúde, salientando o papel do movimento das “marés brancas”. Num segundo momento, apresentamos uma análise seletiva dos principais dados sobre os efeitos da Grande Recessão no país, centrando-nos em especial nos resultados sobre a saúde mental e nas desigualdades na saúde e na utilização do sistema de saúde. Concluímos que as principais políticas têm de ser direcionadas para “as causas das causas” da desigualdade na saúde, o que é um desafio complicado na fase atual do capitalismo. Palavras-chave: crise económica, desigualdades em saúde, Espanha, fatores socioeconómicos, medidas de austeridade, saúde mental.

68 Juan Antonio Córdoba-Doña, Antonio Escolar-Pujolar Evidence on how the previous and current crises have affected the well-being of the population is still fragmented and uncertain, particularly with respect to health inequalities. Alongside this, in recent years the focus has been more on studying the impacts of post-crisis cutbacks on health, especially in Europe (Toffolutti and Suhrcke, 2019). Several mechanisms have been suggested to explain the effects of the global financial crisis and associated structural reforms on health outcomes. Kentikelenis proposed three pathways by which austerity measures could affect health: (i) policies directly target health systems; (ii) policies have an indirect effect on health systems; (iii) policies affect the social determinants of health (Kentikelenis, 2017). More specifically, it has been claimed that the most obvious effects of the austerity-driven welfare reforms (that have taken place) since 2008 have been channeled through social welfare cuts and labor market policies (Ruckert and Labonté, 2017). Spain is generally regarded as one of the European countries most affected by the Great Recession that followed the global financial crisis of 2008 (Ministerio de Sanidad, Consumo y Bienestar Social, 2018a). According to the foregoing considerations, it is worth highlighting the important role played not only by the cyclical change in unemployment rates but also by the high structural unemployment in Spain that has persisted for several decades. These aspects have been thoroughly evaluated in multiple studies in recent literature. However, much less attention has been paid to date to the role of the policies implemented that affect the performance of the health system. Besides this, any attempt to gain a better understanding of the consequences of the crisis and subsequent restrictive policies for the welfare state, especially the health sector, should include the history of the Spanish National Health System (SNHS) from the middle of the last century onwards. To date, analyses of the impacts of the Great Recession on health have been mostly based on very recent historical frameworks, with scant evaluation of the relations between political power and health policies. A description, even in a very summarized form, of the historical roots of our national health system, makes the changes that have taken place during our short democratic history more understandable as do those that have developed subsequently during the Great Recession, under the auspices of the adjustment policies imposed by the European Union (EU) together with Spanish governments (budgetary cuts, personnel reductions and privatizations, among others). This study aims to contribute to this area of research by evaluating the impacts of the economic recession starting in 2008 on health and health inequalities, with emphasis on the historical process and previous economic and political context, and does not limit its analysis to the consequences of the steep fall in GDP and the sharp increase in unemployment and precariousness rates.

69 The Great Recession and Health Inequalities in Spain We first present a historical overview, ranging from the period of the Franco dictatorship, through the democratic era, to the period of the Great Recession, where we focus especially on citizens’ responses to austerity measures within the health system – highlighting the “white tides” movement – which, according to our hypothesis, may have been a buffer against the negative consequences of austerity policies. In the second part of this study, we provide a selective review of the main scientific findings on the effects of the Great Recession in Spain, covering most of the original papers published in international health-related journals in English and Spanish up to November 2018, as well as selected documents drawn from the reference lists of relevant articles. Our review focuses particularly on the effects of the Great Recession on mental health outcomes and on inequalities in health and healthcare utilization.

PART 1. HISTORICAL BACKGROUND

THE LEGACY OF FRANCOISM (1939-1975) From the end of the Civil War in 1939 until the first democratic elections in 1977 the Franco dictatorship’s approach to public health was based on a division between health care services, which were under the control of Falangist ministers in the Ministry of Labor, and public health services, which were the responsibility of the Ministry of the Interior, under the supervision of Catholic military officials (Rodríguez-Ocaña and Martínez-Navarro, 2008). As early as 1967, in a report on the organization of the health services in Spain, Dr. Fraser Brockington, a World Health Organization (WHO) consultant, criticized the Franco administration for failing to establish a Ministry of Health and retaining a system in which the various aspects of health services were dispersed across different ministries (Brockington, 2018 [1967]). To a large extent, Franco’s government limited its efforts to maintaining the health system designed in the Second Republic (Rodríguez-Ocaña, 2008). In the middle of the civil war, the Republican government tried to establish something resembling a national health service, as specified in a document of the Popular Front “[...] the State will take care that each man or woman of the people remains healthy and is duly treated if he or she falls ill” (Huertas, 2000: 41).1 For almost 40 years the Franco regime maintained a very centralized, paternalistic health system that was extremely fragmented (Pons-Pons and Vilar-Rodríguez, 2011; Aguilar, 2010). Brockington’s (2018 [1967]: 10) report stated that “the health of the community constitutes a unitary domain that suffers if it is broken down into different and independent sectors; the diversity of efforts and the lack of integration of services

1 All the translations were made by the authors.

70 Juan Antonio Córdoba-Doña, Antonio Escolar-Pujolar are harmful”. It also stressed that “the principles of social and preventive medicine are conspicuous by their absence” (ibidem: 3), a problem that remains, at least to some extent, to this day. It was not until the introduction of democracy that health care was recognized constitutionally as a right of citizenship.

CHANGES DURING THE FIRST PERIOD OF DEMOCRACY (1977-1986) AND CONSOLIDATION OF THE

NATIONAL HEALTH SYSTEM (1987-1992) When democracy was introduced, Spain’s first democratic government inherited a health system that had serious deficiencies in outpatient health care and out-of-date public health services and had ignored the country’s changing epidemiological profile, which had come to be dominated by non-communicable diseases. There were also serious deficiencies in health information systems and in the training of medical and public health professionals. Internationally the 1970s were marked by a major global economic crisis, and rising health care costs meant that the need to reform Western health systems entered the scientific and institutional agendas (Lorraine and Götze, 2011). The Laframboise- Lalonde Report had shown that biomedical interventions were only one of the influences on health, which was more strongly associated with social, environmental and lifestyle factors (Lalonde, 1974). It followed that existing health policies should be replaced by policies that prioritized prevention and health promotion and built people’s capacity to manage their own health and well-being. In 1978, the Alma-Ata Conference endorsed moves to challenge the then dominant hospital-centric model of health care and reaffirmed the centrality of universal health care to improve the health of the population, emphasizing that the main focus should be on primary care (WHO, 1978). The creation of Spain’s first Ministry of Health in 1977, two years after the death of the dictator Franco, did not lead to a substantial modification in the programs or territorial organization of the previous health system. It was not until the Spanish Socialist Workers Party (PSOE) entered government in 1982 that enough momentum was generated to set in motion a whole series of legislative initiatives aimed at establishing a welfare state that would put Spain on the same level as other European countries. The enactment of the General Health Law (Ley General de Sanidad, LGS) in 1986 stood out amongst these initiatives (Magro, 2016). The LGS was underpinned by three basic aims: to reorganize primary health care, to encourage community participation and to implement inter-sector policies. Amongst the greatest achievements of these reforms were the universalization of health coverage (98.5% in 1995), the introduction of the specialization in Family and Community Medicine, greater

71 The Great Recession and Health Inequalities in Spain administrative integration of the healthcare network and an improvement in the quality of care (Benach, 2018). The devolution of health competencies to the 17 Autonomous Communities started before the enactment of the LGS. This process enabled the first modernization of the structure and services provided by health care units (hospitals and outpatient services) and was not completed until 2002. At present – in very general terms – the Health Departments of each region set their own annual budgets and purchase health care services from Regional Health Services (SRSs), which are in charge of the management of hospitals, clinics and primary care centers. Health Departments may also contract services 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 at the 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). Over the course of a decade (1982-1992), an intensive program of reform was implemented, albeit unevenly across regions; this was accompanied by major investments in infrastructure and human resources, especially in relation to the incorporation of family and community medicine specialists and nursing professionals into the new primary care centers (Rodríguez-Ocaña et al., 2008). In spite of these efforts, the health system continued to be focused primarily on assistance, prioritizing existing illness over the promotion of health; the biomedical continued to dominate and there was a certain disregard for the social determinants of health and community action in health (Benach, 2018). Although initially the objectives of the new primary care centers (Health Centers) were formulated in accordance with the principles of Alma-Ata and the Ottawa Charter, the rise of the neoliberal tide led to their progressive replacement by objectives couched in terms of the management of care processes and based on a vision of an internal market and the implementation of programs aimed at modifying individual lifestyles.

THE RISING OF THE NEOLIBERAL TIDE: COUNTER-REFORMS OF THE HEALTH SYSTEM (1990-2018) In 1990, only four years after the enactment of the LGS and with the European Community pressing Spain to reduce its public deficit, the PSOE government set up a commission of experts known as the “Abril Commission”. Its final report noted that there was a need to introduce private management of public health services, to extend private sector participation in publicly-funded care, to separate funding and provision of 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 for privatization

72 Juan Antonio Córdoba-Doña, Antonio Escolar-Pujolar was delayed for a few years, but it received further support after the approval of Law 15/1997, which is still in force. This law enabled new forms of management of the SNHS (BOE, 1997). It made it legal for provision and management of health and social-health services to be carried out by means of agreements or contracts with public or private persons or entities. Policies, based on this law, that were promulgated during the period 1996-2004 by governments led by the Popular Party (PP), fueled an increase in private management of publicly-funded services (FADSP, 2017). In the regions where PP governments predominated, privatization initiatives took the form of public-private partnerships for the construction and management of hospitals, outsourcing of healthcare activities (mainly surgery), diagnostic procedures and complementary services (FADSP, 2017; Ponte-Mittelbrun, 2005). Although regions with PSOE governments opted for policies that reflected a greater commitment to a public health system, they passed laws incorporating some of the recommendations of the Abril Report. However, the most serious attack on the public health model defined in the LGS occurred in 2012, in the midst of the Great Recession, thanks to the enactment by the PP government of Royal Decree-Law 16/2012 (BOE, 2012). This decree was part of the neoliberal austerity policies promoted by the EU, which were designed to reduce public spending and prioritize debt repayment. The decree linked the right to health care to the condition of being insured, breaking the principle, which had until then prevailed in 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 from health care, with 873,000 health cards being withdrawn from foreign residents (Médicos del Mundo, 2013). The replacement rate for public sector retirements was limited 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 states among its general provisions “[...] access to the National Health System under conditions of equity and universality is a fundamental right of every person” (BOE, 2018). Neoliberalism’s penetration of healthcare field and the neoliberal recipe for austerity in public spending have reached all areas of healthcare in Spain, affecting specialist services the most and influencing the ideas of politicians and managers of public health care services (Navarro, 2012). This penetration stalled in 2011 when citizens mobilized strongly in defense of public health services. This mobilization was underpinned by the strongly favorable opinion that the Spanish population has of the SNHS, despite the impact of neoliberal austerity policies (Sánchez-Bayle and Fernández-Ruiz, 2018).

73 The Great Recession and Health Inequalities in Spain

THE GREAT RECESSION AND ITS COLLATERAL EFFECTS ON THE SOCIAL HEALTH SYSTEM. SOCIAL

INEQUALITY SPIKES (2008-2018) The first manifestation of the Great Recession in Spain was the bursting of the real estate bubble, generated over the decade prior to the 2008 crisis by a very lax credit policy and, by extension, the breakdown of the speculative instruments created and used by US investment banks and their insurance companies (Weissman, 2009). The incompetence of the regulatory bodies, mainly the Bank of Spain, allowed an unsustainable expansion of credit to families and companies in the real estate sector (Navarro, 2012; Ekaizer, 2018). The Spanish banks, especially the savings banks, which transferred speculative capital from Central European banks, were particularly affected. Eventually, the government decided to offer the banks a publicly-financed bailout which, although officially estimated at 122 billion euros by the Court of Auditors, would rise to some 300 billion euros if other types of indirect aid were taken into account (Ekaizer, 2018). Spain’s public debt which, at 35.5%, had been amongst the lowest in the EU in 2007 rose to 99.0% of GDP in 2016 (Delgado et al., 2018). The priority 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 in September 2011 on a rapid reform to the Constitution (BOE, 2011), making controlling the deficit an absolute priority that took precedence over other economic measures that might mitigate the negative impact of the Great Recession. 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 youth unemployment rate was above 50%, representing the destruction of almost 4 million jobs between 2007 and 2014. There has also been a deterioration in the quality of employment, with an increase in part-time hiring of 16-29 years old from 26% in 2007 to 44% in 2016. Only 48% of the population affiliated to the social security system in 2017 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, with families 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 Great Recession 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 the EU. Neoliberal austerity measures led to a fall in public health expenditure as a percentage of total health expenditure, from 73.6% in 2009 to 70.8% in 2017 (OECD,

74 Juan Antonio Córdoba-Doña, Antonio Escolar-Pujolar 2018). In absolute terms, this represents a cut of 15-21 billion euros and is reflected in the loss of 9,600 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 public health services, private spending on health increased from 26.4% in 2008 to 29.2% in 2017. As the historian Josep Fontana pointed out,

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

RESISTANCE TO AUSTERITY POLICIES IN THE HEALTH SECTOR. THE SOCIAL PHENOMENON OF THE

WHITE TIDES Throughout the different stages of democratic government in Spain, there have been civil movements arguing in favor of the right to health as a common good that should not be subject to the law of markets. One of the most notable groups campaigning in support of the SNHS in the past 35 years is the Federation of Associations for the Defense of Public Health (FADSP) (Palomo, 2011). During the last two decades, FADSP was the core group in the formation of multiple Platforms in Defense of the Public Health System throughout the country (FADSP, 2018a). The emergence of the 15-M phenomenon in Madrid and other Spanish cities in 2011, as an outburst of indignation against neoliberal austerity policies, was the most remarkable episode of social mobilization in defense of the welfare state in Spain since the introduction of democracy. The enormous discontent that followed repeated cases of corruption in the largest parties (PSOE and PP) contributed to the birth of movements of outraged citizens, collectively known as mareas blancas (white tides). Organized regionally, the movement mobilizes citizens in defense of the SNHS, against cuts and privatization plans, and also provides a channel by which citizens can express their will, in the absence of effective citizen representation on the governing bodies of the regional health systems (Matos and Serapioni, 2017). The first white tide was organized in Madrid in response to the regional PP government’s decision to privatize hospitals and primary care centers. Health professionals played a critical role in the formation and activity of the white tide, their

75 The Great Recession and Health Inequalities in Spain legal and media work being particularly powerful; they were able to document the conflicts of interest of politicians promoting privatization initiatives and the private companies 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 primary care centers) in 2014 and led to the resignation of the PP politicians involved. This victory was an enormous incentive and led to the formation of several white tides in other regions, provinces and municipalities. These tides are still active in many parts of Spain. Amongst the achievements of the white tides, it is worth highlighting the fact that the privatization and dismantling of the health system are now on the agenda of political organizations and state institutions. The white tides have shown that when citizen mobilization is unified, massive and sustained, it can paralyze privatization processes (Beiras and Sánchez-Bayle, 2015). The huge deterioration in the working conditions of health workers, especially in primary care, has led to a reaction that is taking shape as we write this text – in late 2018 – but includes strikes and demonstrations by health professionals in several Autonomous Communities (FADSP, 2018b). The activities of white tides have not been limited to defending the SNHS and attempting to reverse budget cuts: “[...] we have started to talk about and act on health and 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 progressive medicalization of the SNHS, promoted by the health insurance industry and the big pharma-techno-industrial complex” (Burlage et al., 2018: 70). During the dismantling of the social state, the white tides have helped to open up a public space where conflicts can be discussed, solidarity can be generated or a common will to cope with the uncertainty and suffering generated by the neoliberal individualizing of stress can be articulated (Solé Blanch, 2018). In the face of contemporary capitalism, with its hostility to life, the defense of justice and equity remains the objective for the white tides and similar citizens’ movements.

PART 2. IMPACT OF THE CRISIS ON HEALTH AND HEALTH INEQUALITIES IN SPAIN Before addressing the special features of the Spanish case, we need to consider some context-specific factors and methodological considerations that have been raised in relation to the apparent inconsistencies in the associations between crises and subsequent health outcomes (Suhrcke and Stuckler, 2012). First, there have been national differences in the impact of economic crises that appear to be related to the

76 Juan Antonio Córdoba-Doña, Antonio Escolar-Pujolar generosity of state welfare protection (Norström and Gronqvist, 2015). Second, a wide range of mortality and morbidity indicators has been employed to measure impact, limiting the comparability of studies. Third, the direction of associations found may depend on whether they are based on individual or aggregated data (Martikainen and Valkonen, 1996). Fourth, the health consequences of the ‘normal’, less dramatic variations in the trade cycle may differ substantially from those occurring under exceptional circumstances, such as the recession we are currently experiencing (Ruhm, 2016). Fifth, the short- and long-term health effects of crises, especially on longevity or mortality, may diverge. Finally, one of the main methodological considerations is the difference between average effects in the population and specific group effects (Marmot and Bell, 2009). When considering this aspect, caution should be applied to the socio-economic variable used in the analysis of health inequalities. For instance, one of the characteristics of the recession in Spain is that young adults have been more deeply affected by unemployment and income reductions than other adults. Hence there has been 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 pensions but have more health problems – in higher income brackets, yielding a reduction in income-related health inequalities, as shown in a recent study assessing income inequalities in self-rated health (Coveney et al., 2016). In the following subsections, we present a summary of the main effects of the crisis and austerity measures on inequality in key health outcomes.

MENTAL HEALTH OUTCOMES The impact of the Great Recession on mental health in Spain has been thoroughly investigated since its onset. With some exceptions, researchers have used repeated cross-sectional studies, extracting data from population-based surveys, such as the National Health Survey. The vast majority of studies report an unambiguous negative association between the recession, subsequent neoliberal measures and mental health. A longitudinal study based on primary data from GP consultations between 2006 and 2010 (Gili et al., 2013) represented a milestone in research into the impact of the recession 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 families experiencing unemployment and mortgage payment difficulties. Multi-country research based on the European Social Survey (2006-2014) revealed that the negative consequences of the recession for mental health (measured by depressive feelings) were evident in Spain and recommended that particular attention should be paid to the

77 The Great Recession and Health Inequalities in Spain economically inactive and precariously employed (Reibling et al., 2017). Another publication based on the same data source found that Spaniards showed low social optimism and high levels of depressive symptoms, and attributed the deterioration in mental health over the period 2008-2013 to the financial crisis (Chaves et al., 2018). Several studies have found an increase in the prevalence of poor mental health during the crisis period compared with the pre-crisis period. This increase has been attributed to 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 the prevalence of precarious employment and lower health spending per capita (Ruiz-Pérez et al., 2017a). Research into sex differences found that the recession has had a greater impact on men’s mental health (Bacigalupe et al., 2016; Moncho et al., 2018). A study using four waves of data from the Basque Health Survey (1997-2013) did not observe any association between employment status or social class and the increase in poor mental health (Bacigalupe et al., 2016). This lack of association was corroborated by another study in Andalusia which, instead, found that the negative impact of the recession on mental health was concentrated amongst those with secondary education, whether employed or unemployed (Córdoba-Doña et al., 2016) The impact of the financial crisis on mental health appears to have differed between age groups. Specifically, the risk of suffering from mental health problems for children with 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 young population vary according to the data source (Aguilar-Palacio et al., 2015; Medel-Herrero and Gómez-Beneyto, 2017). Finally, education- and income-related inequalities amongst the over-50s in Catalonia were found to have increased from 2006 to 2015 (Spijker and Zueras, 2018).

SUICIDE AND SUICIDAL BEHAVIOR Spain has for decades had low suicide rates relative to the European average. Although in the wake of the recession several countries have seen an increase in suicides or a change to the previous downward trend (De Vogli et al., 2013), it is not entirely clear what the situation in Spain is. López-Bernal et al. (2013) reported an 8% increase in suicides based on an interrupted time series analysis with several methodological drawbacks, including the limited time span 2010-2015. Ruiz-Pérez et al. (2017b) found that the financial crisis was associated with suicides at two different times – the double-dip recession – and not with a sustained trend after its onset. In contrast Álvarez-Gálvez et al. (2017), who measured monthly rates, observed an

78 Juan Antonio Córdoba-Doña, Antonio Escolar-Pujolar increase in the period 2011-2014 but not before then, suggesting that the impact of economic problems on suicide may have been delayed by policies designed to mitigate their effects. These results are consistent with an earlier study by Ruiz-Ramos et al. (2014), who reported that suicide rates in Spain had decreased between 1999 and 2011, in both men and women. The lack of an overall increase in the suicide rate was also observed in Catalonia from 2010, although there were increases in several subgroups (Saurina et al., 2015). A study performed in the Basque Country and the city of Barcelona showed that educational inequalities 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 the crisis there was a correlation between unemployment and suicide that has weakened during the recent financial crisis (VV. AA., 2017). Interestingly, in contrast with the variability in suicide mortality, there has been a consistent increase in attempted suicide since the Great Recession, especially in the working age population (Córdoba-Doña et al., 2014; Celada et al., 2017).

MORTALITY According to the majority of authors, overall mortality in Spain has not changed since the Great Recession, although there is some controversy about the rate of decline relative 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. For instance, it has recently been reported that cancer mortality has been decreasing more slowly since the onset of the crisis (VV. AA., 2018b), while amenable mortality decreased more significantly than overall mortality between periods, though unevenly distributed among causes of death (Nolasco et al., 2018). Moreover, an earlier study reported that in persons aged 60 years or older mortality appears to be decreasing more slowly than would have been expected had the recession not occurred (Benmarhnia et al., 2014). At European level, crisis-related economic conditions were not associated with widening health inequalities in mortality until 2014 (VV. AA., 2018c). However, this conclusion is not supported by the results of several studies based on local and regional data. In Andalusia, social inequalities in male mortality have increased since the early years of the crisis and this is linked to a deeper reduction in mortality rates amongst more educated men (Ruiz-Ramos et al., 2014). A study which took an ecological approach to mortality found that between 2008 and 2011 it increased more relative to the pre-crisis period in deprived neighborhoods of Barcelona than in affluent neighborhoods (Maynou Pujolras et al., 2016). However, it remains to be determined

79 The Great Recession and Health Inequalities in Spain whether deaths from specific causes may have been disproportionately affected by the recession in specific vulnerable subgroups (Alonso et al., 2017).

IMMIGRANTS’ HEALTH AND HEALTHCARE One of the first assessments of the impact on the Great Recession on immigrant healthcare access in Spain (covering 2006-2012) did not find any deterioration, possibly because the SNHS performed fairly well until 2012 (García-Subirats, 2014). Using the same databases, Gotsens et al. (2015) found that immigrants who arrived in Spain before 2006 had worse health status than natives and posited that the recession was responsible for the loss of the so-called healthy immigrant effect. Cimas et al. (2016) evaluated the implementation of the above-mentioned Royal Decree-Law 16/2012 of the Spanish government, which limited immigrants’ previously comprehensive access to public health services. They found that implementation varied geopolitically, reflecting the complexity of nation-wide regulation in a highly decentralized system (ibidem). A more recent review also showed that regional legislation protecting the rights of undocumented migrants may have limited the deleterious health effects of the recession and subsequent austerity measures on this group (Peralta-Gallego et al., 2018). One of the few publications to compare native and migrant populations found that immigrant women and men were more likely to use GP and emergency services than their native counterparts (Rodríguez-Álvarez et al., 2018). There are limits to how effectively one can assess immigrants’ access to healthcare services using quantitative data extracted from population-based surveys. A qualitative study designed to address the drawbacks of quantitative research found an exacerbation of pre-existing barriers to the use of healthcare services and the appearance 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 and interpersonal resources of the health services during the economic crisis (ibidem, 2018).

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

80 Juan Antonio Córdoba-Doña, Antonio Escolar-Pujolar observed that the prevalence of small-for-gestational-age births has increased during the crisis, interrupting the previous downward trend. In addition, the pre-crisis inequalities in perinatal health have persisted, although low birth weight proved to be more strongly associated with maternal educational level after the onset of the crisis than in the previous period (ibidem). These findings are consistent with a broadly- based study using data for 2005-2015 from 16 European countries. This study concluded that countries that implemented more severe austerity measures have experienced an increase in the prevalence of low birth weight together with an increase in material deprivation in families with no more than primary education (Rajmil et al., 2018).

USE OF HEALTHCARE SERVICES López-Valcárcel and Urbanos-Garrido have studied a wide variety of health service performance indicators during the crisis and related them to diverse socioeconomic variables. Their research, together with contributions from other scholars, is included in a very recent comprehensive review, edited by the Spanish Ministry of Health, of the impact of the current economic recession on health and use of healthcare services (Ministerio de Sanidad, Consumo y Bienestar Social, 2018a). The overall use of health care services was unchanged during the early years of the crisis, although a study by Urbanos-Garrido and Puig-Junoy (2014) described how waiting times and waiting lists for surgery increased, in parallel with the increase in dissatisfaction with the SNHS that has been detected in health surveys. More specifically, the average waiting time for surgery rose from 63 to 76 days between 2009 and 2012 (López-Valcárcel and Barber, 2017) and increased further to 93 days in June 2018 (Ministerio de Sanidad, Consumo y Bienestar Social, 2018b). No significant socioeconomic differences in the frequency of use of physician consultations 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) found that, in relative terms, the recession has had a greater detrimental effect – a decrease in utilization – on low-income groups with respect to specialist appointments and hospitalizations, whereas it has worked to their advantage with respect to emergency services and GP consultations (ibidem). A study in Andalusia, comparing 2007 to 2012, found that horizontal inequity in the use of GPs and specialists had reduced, but argued that the increase in lower income groups’ use of hospitalizations and emergency services could indicate that their access to appropriate primary care services had been curtailed (Córdoba-Doña et al., 2018). Increases in the use of emergency services associated with poor mental health and

81 The Great Recession and Health Inequalities in Spain limitations on daily activities in lower income groups have also been reported (Pereira et 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 et al., 2015). Finally, the Health Barometer data from 2014 to 2016 showed that unemployed people were four times more likely to discontinue medication because they could not afford it than qualified workers and professionals, which raises important questions about equity of access to treatment (Ministerio de Sanidad, Consumo y Bienestar Social, 2018a).

CONCLUSIONS This extended historical contextualization and review of the literature add to the growing body of research that indicates that the Great Recession and neoliberal austerity measures have so far had a deleterious impact on mental health and suicidal behavior, especially in the middle-aged Spanish population. We highlight the importance of these findings, often disregarded in favor of research that focuses too much on the weak or unclear effects of the recession on general mortality and self- rated health. Although it is not yet possible to observe all the health consequences of the Great Recession, it seems very plausible that the aggravation of social inequalities during these years, and the detrimental effect on other structural and proximal determinants, will be translated into medium- and long-term negative effects on health, with the latency depending on the nature of the health outcome in question. For example, it is only very recently, several years into the recession in Spain, that increases in poor perinatal outcomes have been reported. The observed effects of the recession appear to be mediated by unemployment, loss of access to housing and economic hardship, all of which disproportionately affect vulnerable populations. The effects on health inequalities will also depend on the indicators of socio-economic position employed. In Spain, the young population – which is relatively highly educated – has suffered most from increased unemployment, precarious jobs and cut wages and this is why we see paradoxical results such as the reduction in income inequality, alongside an increase in educational inequality in some health outcomes. In general, the results relating to equity in the use of health services indicate that the SNHS 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 of overstraining themselves. Some indicators – such as the growing dissatisfaction of the population – suggest that by 2013 the system’s buffer capacity was exhausted. Although inequalities in access to medication and timely admission to services are

82 Juan Antonio Córdoba-Doña, Antonio Escolar-Pujolar being detected, with the information currently available it is not possible to assess the impact on health outcomes that is due to deterioration in the quality of services directly. The deleterious effects on immigrants’ access to healthcare are clear from qualitative research carried out in recent years, although the high regional variability in the implementation of restrictive measures prevents us from reaching an overall conclusion. Finally, if we put the Great Recession and the consequences that have flowed from it into a broad temporal perspective, it does not seem appropriate to consider the crisis or recession as a specific event or a temporary variation/fluctuation occurring in a certain country. We propose that the world has entered a new, qualitatively different era, as these changes are taking place in the context of a global crisis (climatic, cultural and social) that affects the majority of the structural determinants of health and health inequalities 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 of people must be central, and that achieving this is a complicated challenge in the current phase of capitalism.

Edited by Ricardo Cabrita

JUAN ANTONIO CÓRDOBA-DOÑA Unidad de Medicina Preventiva y Salud Pública, Hospital Universitario de Jerez, Área de Gestión Sanitaria de Jerez, Costa Noroeste y Sierra de Cádiz | Instituto de Investigación Biomédica e Innovación de Cádiz, INIBICA Ronda de Circunvalación, s/n., Jerez de la Frontera, 11407 España Contact: [email protected]

ANTONIO ESCOLAR-PUJOLAR Consejería de Salud de la Junta de Andalucía, Delegación Territorial en Cádiz (retired) Cádiz, España Contact: [email protected]

Received on 08.01.2019 Accepted for publication on 23.06.2019

83 The Great Recession and Health Inequalities in Spain

REFERENCES Abásolo, Ignacio; Saez, Marc; López-Casasnovas, Guillem (2017), “Financial Crisis and Income-Related Inequalities in the Universal Provision of a Public Service: The Case of Healthcare in Spain”, International Journal for Equity in Health, 16, 134. Aguilar, Manuel (2010), “La huella de la beneficencia en los Servicios Sociales”, Zerbitzuan, 48, 9-16. Accessed on 12.10.2018, at http://www.zerbitzuan.net/documentos/zerbitzuan/La%20huella%20de%20la%20benefice ncia.pdf. Aguilar-Palacio, Isabel; Carrera-Lasfuentes, Patricia; Rabanaque, María José (2015), “Youth Unemployment and Economic Recession in Spain: Influence on Health and Lifestyles in Young People (16-24 Years Old)”, International Journal of Public Health, 60(4), 427-435. Alonso, Ignacio; Vallejo, Fernando; Regidor, Enrique; Belza, M José; Sordo, Luis; Otero-García, Laura; Barrio, Gregorio (2017), “Changes in Directly Alcohol-Attributable Mortality During the Great Recession by Employment Status in Spain: A Population Cohort of 22 Million People”, Journal of Epidemiology & Community Health, 71(8), 736-744. Alvarez-Gálvez, Javier; Salinas-Perez, Jose Antonio; Rodero-Cosano, María Luisa; Salvador- Carulla, Luis (2017), “Methodological Barriers to Studying the Association between the Economic Crisis and Suicide in Spain”, BMC Public Health, 17(1), 694. Arroyo-Borrell, Elena; Renart, Gemma; Saurina, Carme; Saez, Marc (2017), “Influence Maternal Background has on Children’s Mental Health”, International Journal for Equity in Health, 16, 63. Bacigalupe, Amaia; Esnaola, Santiago; Martín, Unai (2016), “The Impact of the Great Recession on Mental Health and Its Inequalities: The Case of a Southern European Region, 1997-2013”, International Journal for Equity in Health, 15, 17. Bartoll, Xavier; Palència, Laia; Malmusi, Davide; Suhrcke, Marc; Borrell, Carme (2014), “The Evolution of Mental Health in Spain during the Economic Crisis,” European Journal of Public Health, 24(3), 415-418. Beiras, Hixinio; Sánchez-Bayle, Marciano (eds.) (2015), La sanidad no se vende. Manual para la Defensa de la Sanidad Pública. Madrid: Akal. Benach, Joan (2018), “El Sistema Nacional de Salud español: ¿Cómo se originó? ¿Qué logró? ¿A dónde debería ir?”, Sin Permiso, January 29. Accessed on 12.10.2018, at http://www.sinpermiso.info/printpdf/textos/el-sistema-nacional-de-salud-espanol-como-se- origino-que-logro-a-donde-deberia-ir. Benmarhnia, Tarik; Zunzunegui, Maria-Victoria; Llácer, Alicia; Béland, Francois (2014), “Impact of the Economic Crisis on the Health of Older Persons in Spain: Research Clues Based on an Analysis of Mortality. SESPAS Report 2014”, Gaceta Sanitaria, 28(suppl. 1), 137-141. BOE – Boletín Oficial del Estado (1997), Ley 15/1997, de 25 de abril, sobre habilitación de nuevas formas de gestión del Sistema Nacional de Salud. BOE núm. 100, Madrid. Accessed on 07.09.2018, at https://www.boe.es/buscar/doc.php?id=BOE-A-1997-9021.

84 Juan Antonio Córdoba-Doña, Antonio Escolar-Pujolar

BOE – Boletín Oficial del Estado (2011), Constitución Española. Jefatura del Estado, Reforma del artículo 135 de la Constitución Española, 27 de septiembre. BOE núm. 233. Accessed on 14.09.2018, at https://www.boe.es/eli/es/ref/2011/09/27/(1)/dof/mul/pdf. BOE – Boletín Oficial del Estado (2012), Real Decreto-ley16/2012, de 20 de abril, de medidas urgentes para garantizar la sostenibilidad del Sistema Nacional de Salud y mejorar la calidad y seguridad de sus prestaciones. BOE núm. 98. Accessed on 12.11.2018, at https://www.boe.es/buscar/pdf/2012/BOE-A-2012-5403-consolidado.pdf. BOE – Boletín Oficial del Estado (2018), Real Decreto-ley 7/2018, de 27 de julio, sobre el acceso universal al Sistema Nacional de Salud. BOE núm. 183. Madrid. Accessed on 20.09.2018, at https://www.boe.es/boe/dias/2018/07/30/pdfs/BOE-A-2018-10752.pdf. Borrell, Carme; Marí-Dell’Olmo, Marc; Gotsens, Mercè; Calvo, Montse; Rodríguez-Sanz Maica; Bartoll, Xavier; Esnaola, Santiago (2017), “Socioeconomic Inequalities in Suicide Mortality Before and After the Economic Recession in Spain”, BMC Public Health, 17(1), 772. Brockington, Fraser (2018), “Informe sobre la organización de los servicios sanitarios en España”. Granada: Universidad de Granada. Translated by Esteban Rodríguez Ocaña [orig. 1967]. Accessed on 14.09.2018, at https://multimedia.elsevier.es/PublicationsMultimediaV1/item/multimedia/S021391111830 0918:mmc1.pdf?idApp=WGSE. Burlage, Roob; Anderson Matthew (2018), “The Transformation of the Medical-Industrial Complex: Financialization, the Corporate Sector, and Monopoly Capital”, in Howard Waitzkin (coord.), Health Care Under the Knife. Moving beyond Capitalism for Our Health. New York: Monthly Review Press, 69-82. Calzón-Fernández, Silvia; Fernández Ajuria, Alberto; Martín, José Jesús; Murphy, Matthew Joseph (2015), “The Impact of the Economic Crisis on Unmet Dental Care Needs in Spain”, Journal of Epidemiology and Community Health, 69(9), 880-885. Celada, José; Quiroga-Fernández, Antonio; Mohedano-Moriano, Alicia; Aliaga Vera, Ignacio; Fernández Pérez, Cristina; Martín Conty, José Luis (2017), “Evolución de la tentativa suicida atendida por los Servicios de Emergencias Médicas de Castilla-La Mancha tras la crisis económica, España”, Emergencias, 29(4), 247-252. Chaves, Covadonga; Castellanos, Tamara; Abrams, Matthew; Vazquez, Carmelo (2018), “The Impact of Economic Recessions on Depression and Individual and Social Well-Being: The Case of Spain (2006-2013)”, Social Psychiatry and Psychiatric Epidemiology, 53, 977-986. Cimas, Marta; Gullón, Pedro; Aguilera, Eva; Meyer, Stefan; Freire, José Manuel; Perez-Gomez, Beatriz (2016), “Healthcare Coverage for Undocumented Migrants in Spain: Regional Differences after Royal Decree Law 16/2012”, Health Policy, 120(4), 384-395. Córdoba-Doña, Juan Antonio; San Sebastián, Miguel; Escolar-Pujolar, Antonio; Martínez-Faure, Jesús Enrique; Gustafsson, Per E. (2014), “Economic Crisis and Suicidal Behaviour:

85 The Great Recession and Health Inequalities in Spain

The Role of Unemployment, Sex and Age in Andalusia, Southern Spain”, International Journal for Equity in Health, 13(1), 55. Córdoba-Doña, Juan Antonio; Escolar-Pujolar, Antonio; San Sebastián, Miguel; Gustafsson, Per E (2016), “How Are the Employed and Unemployed Affected by the Economic Crisis in Spain? Educational Inequalities, Life Conditions and Mental Health in a Context of High Unemployment”, BMC Public Health, 16, 267. Córdoba-Doña, Juan Antonio; Escolar-Pujolar, Antonio; San Sebastián, Miguel; Gustafsson, Per E (2018), “Withstanding Austerity: Equity in Health Services Utilisation in the First Stage of the Economic Recession in Southern Spain”, PLOS ONE, 13(3), e0195293. DOI: 10.1371/journal.pone.0195293 Coveney, Max; García Gómez, Pilar; Eddy Van Doorslaer, Eddy; Van Ourt, Tom (2016), “Health Disparities by Income in Spain Before and After the Economic Crisis”, Health Economics, 25(suppl. 2), 141-158. DOI: 10.1371/journal.pone.0195293 Cumbre Social Estatal (2018), “Una década perdida. Análisis de 10 años de recortes”, Unión General de Trabajadores, November 6. Accessed on 26.11.2018, at http://www.ugt.es/sites/default/files/informe_cumbre_social_10_anos_recortes_ultimo.pdf. De Vogli, Roberto; Marmot, Michael; Stuckler, David (2013), “Strong Evidence that the Economic Crisis Caused a Rise in Suicides in Europe: The Need for Social Protection” Journal of Epidemiology & Community Health, 67(4), 298. Delgado, Mar; García, Blanca; Zubimendi, Leonor (2018), “La evolución de la deuda pública en España en 2017”, Boletín Económico, 2. Accessed on 14.09.2018, at https://www.bde.es/f/webbde/SES/Secciones/Publicaciones/InformesBoletinesRevistas/N otasEconomicas/2018/T2/Fich/bene1802-nec7.pdf. Ekaizer, Ernesto (2018), El libro negro. La crisis de Bankia y las Cajas. Como falló el Banco de España a los ciudadanos. Barcelona: Planeta S.A. Eurostat (2017), “Gini Coefficient of Equivalised Disposable Income – EU-SILC Survey”. Spain, 2006-2017. Accessed on 18.11.2018, at https://ec.europa.eu/eurostat/tgm/table.do?tab=table&init=1&plugin=1&pcode=tessi190&l anguage=en. FADSP – Federación de Asociaciones para la Defensa de la Sanidad Pública (2017), “El hospital de Alzira un experimento neoliberal fracasado que se resiste a desaparecer”, November 27. Accessed on 28.10.2018, at http://www.fadsp.org/index.php/sample- sites/manifiestos/1569-el-hospital-de-alzira-un-experimento-neoliberal-fracasado-que-se- resiste-a-desaparecer. FADSP – Federación de Asociaciones en Defensa de la Sanidad Publica (2018a), 35 años defendiendo la Sanidad Pública. Madrid: FADSP. Accessed on 17.10.2018, at http://www.fadsp.org/index.php/publicaciones/libros-a- folletos?task=view&id=18&catid=54. FADSP – Federación de Asociaciones para la Defensa de la Sanidad Pública (2018b), “La FADSP ante las huelgas en Atención Primaria”, November 28. Accessed on 12.12.2018,

86 Juan Antonio Córdoba-Doña, Antonio Escolar-Pujolar

at http://www.fadsp.org/~ab47510/index.php/sample-sites/manifiestos/1820-la-fadsp- ante-las-huelgas-en-atencion-primaria. Fontana, Josep (2013), El futuro es un país extraño. Una reflexión sobre la crisis social de comienzos del siglo XXI. Barcelona: Pasado y Presente. Garcia-Subirats, Irene; Vargas, Ingrid; Sanz-Barbero, Belén; Malmusi, Davide; Ronda, Elena; Ballesta, Mónica; Vázquez, María Luisa (2014), “Changes in Access to Health Services of the Immigrant and Native-Born Population in Spain in the Context of Economic Crisis”, International Journal Environmental Research and Public Health, 11(10), 10182-10201. Gili, Margalida; Roca, Miquel, Basu, Sanjay; McKee, Martin; Stuckler, David (2013), “The Mental Health Risks of Economic Crisis in Spain: Evidence from Primary Care Centres, 2006 and 2010”, European Journal of Public Health, 23(1), 103-108. Gobierno de España (1991), Congreso de los Diputados, Comisión de Política Social y Empleo, “Comisión de Expertos encargada del análisis y evaluación del Sistema Nacional de Salud (Abril Martorell), Conclusiones y Resumen”, 25 de septiembre, Madrid. Accessed on 21.10.2018, at http://www.congreso.es/public_oficiales/L4/CONG/DS/CO/CO_306.PDF. Gotsens, Mercé; Malmusi, Davide; Villarroel, Nazmy; Vives-Cases, Carmen; Garcia-Subirats, Irene; Hernando, Cristina; Borrell, Carme (2015), “Health Inequality between Immigrants and Natives in Spain: The Loss of the Healthy Immigrant Effect in Times of Economic Crisis”, European Journal of Public Health, 25(6), 923-929. Huertas, Rafael (2000), “Política sanitaria: de la dictadura de Primo de Rivera a la IIª República”, Revista Española de Salud Pública, 74, 35-43. Accessed on 10.10.2018, at http://scielo.isciii.es/pdf/resp/v74nmon/huertas.pdf. Kentikelenis, Alexander E. (2017), “Structural Adjustment and Health: A Conceptual Framework and Evidence on Pathways”, Social Science & Medicine, 187, 296-305. Lalonde, Marc (1974), A New Perspective on the Health of Canadians. A Working Document, Government of Canada, Ottawa. Accessed on 12.09.2018, at http://www.phac- aspc.gc.ca/ph-sp/pdf/perspect-eng.pdf. López-Bernal, James A; Gasparrini, Antonio; Artundo, Carlos M; McKee, Martin (2013), “The Effect of the Late 2000s Financial Crisis on Suicides in Spain: An Interrupted Time-Series Analysis”, European Journal of Public Health, 23(5), 732-736. López-Valcárcel, Beatriz González; Barber, Patricia (2017), “Economic Crisis, Austerity Policies, Health and Fairness: Lessons Learned in Spain”, Applied Health Economics and Health Policy, 15(1), 13-21. Lorraine, Frisina D; Götze, Ralf (2011), “Health Care Policy for Better or for Worse? Examining NHS Reforms During Times of Economic Crisis Versus Relative Stability”, Social Policy & Administration, 45, 488-505. Lostao, Lourdes; Geyer, Siegfried; Albaladejo, Romana; Moreno Lostao, Almudena; Santos, Juana M.; Regidor Poyatos, Enrique (2017), “Socioeconomic Position and Health

87 The Great Recession and Health Inequalities in Spain

Services Use in Germany and Spain During the Great Recession”, PLOS ONE, 12(8), e0183325. DOI: 10.1371/journal.pone.0183325 Magro, Fernando (2016), “A los 30 años de la Ley General de Sanidad. La visión de uno de sus artífices”, Acta Sanitaria, April 28. Accessed on 14.10.2018, at https://www.actasanitaria.com/ley-general-de-sanidad-30-anos-despues/. Marmot, Michael; Bell, Ruth (2009), “How Will the Financial Crisis Affect Health?”, BMJ: British Medical Journal, 338(7699), 858-860. Martí, Josep (2018), “Cal canviar l’actual hegemonia del pensament neoliberal també en el terreny de la Salut”, El diari de la sanitat, November 27. Accessed on 24.11.2018, at http://diarisanitat.cat/cal-canviar-lactual-hegemonia-del-pensament-neoliberal-tambe-en- el-terreny-de-la-salut/. Martikainen, Pekka; Valkonen, Tapani (1996), “Excess Mortality of Unemployed Men and Women During a Period of Rapidly Increasing Unemployment”, Lancet, 348(9032), 909- 912. Matos, Ana Raquel; Serapioni, Mauro (2017), “The Challenge of Citizens’ Participation in Health Systems in Southern Europe: A Literature Review”, Cadernos de Saúde Pública, 33(1), e00066716. Accessed on 04.12.2018, at http://www.scielo.br/pdf/csp/v33n1/en_1678- 4464-csp-33-01-e00066716.pdf. Maynou Pujolras, Laia; Saez, Marc; López Casasnovas, Guillem (2016), “Has the Economic Crisis Widened the Intraurban Socioeconomic Inequalities in Mortality? The Case of Barcelona”, Journal of Epidemiology & Community Health, 70(2), 114-124. Medel-Herrero, Álvaro; Gómez-Beneyto, Manuel (2017), “Impacto de la crisis económica del 2008 en el número de jóvenes hospitalizados por patología psiquiátrica”, Revista de Psiquiatría y Salud Mental, 12(1), 28-36. Accessed on 15.09.2018, at https://doi.org/10.1016/j.rpsm.2017.10.002. Médicos del Mundo (2013), “El impacto de la reforma sanitaria sobre el Derecho a la Salud”, September 24. Accessed on 24.10.2018, at http://www.medicosdelmundo.es/derechoacurar/wp-content/uploads/2012/11/Resumen- del-impacto-de-la-reforma-sanitaria-en-el-derecho-a-la-salud-de-la-poblaci%C3%B3n- inmigrante-Casos-documentados.-sin-anexos-sin-casos.pdf. Ministerio de Sanidad, Consumo y Bienestar Social (2018a), “Crisis económica y salud en España”. Accessed on 08.12.2018, at https://www.mscbs.gob.es/estadEstudios/estadisticas/docs/CRISIS_ECONOMICA_Y_SA LUD.pdf. Ministerio de Sanidad, Consumo y Bienestar Social (2018b), “Opinión de los ciudadanos. Barómetro Sanitario”. Accessed on 05.12.2018, at https://www.mscbs.gob.es/estadEstudios/estadisticas/BarometroSanitario/home_BS.htm. Moncho, Joaquín; Pereyra-Zamora, Pamela; Tamayo-Fonseca, Nayara; Giron, Manuel; Gómez- Beneyto, Manuel; Nolasco, Andreu (2018), “Is Recession Bad for Your Mental Health?

88 Juan Antonio Córdoba-Doña, Antonio Escolar-Pujolar

The Answer Could Be Complex: Evidence from the 2008 Crisis in Spain”, BMC Medical Research Methodology, 18, 78. DOI: 10.1186/s12874-018-0538-2 Navarro, Vicente (2012), “The Crisis and Fiscal Policies in the Peripheral Countries of the Eurozone”, International Journal of Health Services, 42(1), 1-7. Nolasco, Andreu; Pereyra-Zamora, Pamela; Sanchis-Matea, Elvira; Tamayo-Fonseca, Nayara; Caballero, Pablo; Melchor, Inmaculada; Moncho, Joaquín (2018), “Economic Crisis and Amenable Mortality in Spain”, International Journal of Environmental Research and Public Health, 15(10). DOI: 10.3390/ijerph15102298 Norström, Thor; Gronqvist, Hans (2015), “The Great Recession, Unemployment and Suicide”, Journal of Epidemiology & Community Health, 69(2), 110-116. OECD (2018), “Health Expenditure Indicators”, OECD Stats. Accessed on 18.11.2018, at https://www.oecd-ilibrary.org/social-issues-migration-health/data/oecd-health- statistics/system-of-health-accounts-health-expenditure-by-function_data-00349-en. Médico Crítico (2016), “Seis dudas y siete gráficas sobre gasto sanitario en España”, Diagonal Periódico, June 23. Accessed on 23.10.2018, at https://www.diagonalperiodico.net/blogs/javierpadillab/6-dudas-y-7-graficas-sobre-gasto- sanitario-espana.html. Palomo, Luis (coord.) (2011), Treinta años del Sistema Sanitario Español (1981-2011). Treinta años de la Federación de Asociaciones para la defensa de la Sanidad Pública. Madrid: FADSP. Peralta-Gallego, Leia; Gené-Badia, Joan; Gallo, Pedro (2018), “Effects of Undocumented Immigrants Exclusion from Health Care Coverage in Spain”, Health Policy, 122(11), 1155-1160. Pereira, Patricia L; Pagá Casanova, Ana; Sanz, Belén (2016), “A ‘Before and After’ in the Use of Emergency Services in Spain? The Impact of the Economic Crisis”, International Journal of Health Services, 46(3), 430-447. Pons-Pons, Jerònia; Vilar-Rodríguez, Margarita (2011), “La implantación del seguro de enfermedad en la España franquista y la exportación del modelo a Hispanoamérica (1942-1962)”, Paper presented at 5tas Jornadas Uruguayas de Historia Económica, 23-25 November, Montevideo, Uruguay. Accessed on 02.10.2018, at http://www.audhe.org.uy/images/stories/upload/vilar%20pons.montevideo2011.pdf. Ponte-Mittelbrun, Carlos (2005), “Neoliberalismo en España: efectos sobre el sistema de salud”, in Federación de Asociaciones para la Defensa de la Sanidad Pública (orgs.), Globalización y salud. Madrid: FADSP, 311-352. Porthé, Victoria; Vargas, Ingrid; Sanz-Barbero, Belén; Plaza-Espuña, Isabel; Bosch, Lola; Vázquez, Maria Luisa (2016), “Changes in Access to Health Care for Immigrants in Catalonia During the Economic Crisis: Opinions of Health Professionals and Immigrant Users”, Health Policy, 120(11), 1293-1303. Porthé, Victoria; Vargas, Ingrid; Ronda, Elena; Malmusi, Davide; Bosch, Lola; Vázquez, M. Luisa (2018), “Has the Quality of Health Care for the Immigrant Population Changed

89 The Great Recession and Health Inequalities in Spain

During the Economic Crisis in Catalonia (Spain)? Opinions of Health Professionals and Immigrant Users”, Gaceta Sanitaria, 32(5), 425-432. Rajmil, Luis; Medina, Antonia; Fernández de Sanmamed, María-José; Mompart-Penina, Anna (2013), “Impact of the Economic Crisis on Children’s Health in Catalonia: A Before-After Approach”, BMJ Open, 3(8), e003286. DOI: 10.1136/bmjopen-2013-003286 Rajmil, Luis; Taylor-Robinson, David; Gunnlaugsson, Geir; Hjern, Anders; Spencer, Nick (2018), “Trends in Social Determinants of Child Health and Perinatal Outcomes in European Countries 2005-2015 by Level of Austerity Imposed by Governments: A Repeat Cross- Sectional Analysis of Routinely Available Data”, BMJ Open, 8(10), e022932. DOI: 10.1136/bmjopen-2018-022932 Regidor, Enrique; Barrio, Gregorio; Bravo, María J; de la Fuente, Luis (2014), “Has Health in Spain Been Declining since the Economic Crisis?”, Journal of Epidemiology & Community Health, 68(3), 280-282. Reibling, Nadine; Beckfield, Jason; Huijts, Tim; Schmidt-Catran, Alexander; Thomson, Katie H.; Wendt, Claus (2017), “Depressed During the Depression: Has the Economic Crisis Affected Mental Health Inequalities in Europe? Findings from the European Social Survey (2014) Special Module on the Determinants of Health”, European Journal of Public Health, 27(suppl. 1), 47-54. Rodríguez-Ocaña, Esteban (2008), “La Sanidad en la II República española, 1931-1939”, in Colectivo de Investigación Histórica Arrabal (eds.), El Centro Secundario de Higiene rural de Talavera de la Reina. 75 aniversario de una experiencia modernizadora en la Sanidad, Colección Mirarte no. 3. Talavera de la Reina: Colectivo de Investigación Histórica Arrabal, 5-12. Accessed on 17.09.2018, at http://hdl.handle.net/10481/20465. Rodríguez-Ocaña, Esteban; Martínez-Navarro, Ferrán (2008), Salud pública en España. De la Edad Media al siglo XXI. Granada: Escuela Andaluza de Salud Pública. Accessed on 20.10.2018, at https://www.ugr.es/~erodrig/EASP_NuevaSaludPublica_1-Historia.pdf. Rodríguez-Álvarez, Elena; Lanborena, Nerea; Borrell, Luisa N. (2018), “Health Services Access Inequalities Between Native and Immigrant in a Southern European Region”, International Journal of Health Services, 108-126. Accessed on 21.11.2018, at https://journals.sagepub.com/doi/abs/10.1177/0020731418809858. Ruckert, Arne; Labonté, Ronald (2017), “Health Inequities in the Age of Austerity: The Need for Social Protection Policies”, Social Science & Medicine, 187, 306-311. Ruhm, Christopher J. (2016), “Health Effects of Economic Crises”, Health Economics, 25(suppl. 2), 6-24. Ruiz-Pérez, Isabel; Bermúdez-Tamayo, Clara; Rodríguez-Barranco, Miguel (2017a), “Socio- Economic Factors Linked with Mental Health during the Recession: A Multilevel Analysis”, International Journal for Equity in Health, 16, 45. DOI: 10.1186/s12939-017-0518-x Ruiz-Pérez, Isabel; Rodriguez-Barranco, Miguel; Rojas-Garcia, Antonio; Mendoza-Garcia, Oscar (2017b), “Economic Crisis and Suicides in Spain. Socio-Demographic and Regional Variability”, European Journal of Health Economics, 18(3), 313-320.

90 Juan Antonio Córdoba-Doña, Antonio Escolar-Pujolar

Ruiz-Ramos, Miguel; Córdoba-Doña, Juan Antonio; Bacigalupe, Amaia; Juárez, Sol; Escolar- Pujolar, Antonio (2014), “Crisis económica al inicio del siglo XXI y mortalidad en España. Tendencia e impacto sobre las desigualdades sociales. Informe SESPAS 2014”, Gaceta Sanitaria, 28(S1), 89-96. Sánchez-Bayle, Marciano (2012), “La contrarreforma sanitaria del Partido Popular”, Observatorio de Salud, 6. Accessed on 14.11.2018, at https://www.upf.edu/documents/3298437/3304538/observatoriosalud6.pdf/c2bb6570- 6e97-4eab-b327-26bc817c3584. Sánchez-Bayle, Marciano; Fernández-Ruiz, Sergio (2018), Sanidad Pública. Entre el éxito y el desastre. Madrid: Tevescop. Saurina, Carme; Marzo, Manel; Saez, Marc (2015), “Inequalities in Suicide Mortality Rates and the Economic Recession in the Municipalities of Catalonia, Spain”, International Journal for Equity in Health, 14, 75. DOI: 10.1186/s12939-015-0192-9 Simó, Juan (2016), “Recortes en gasto sanitario... ¿y en dignidad profesional?”, blog Salud, dinero y atención primaria, July 12. Accessed on 28.11.2018, at http://saludineroap.blogspot.com/2016/07/recortes-en-gasto-sanitario-y-en.html. Solé Blanch, Jordi (2018), “El malestar social bajo la nueva razón neoliberal”, in Jordi Solé Blanch; Asun Pié Balaguer (eds.), Políticas del sufrimiento y la vulnerabilidad. Barcelona: Icaria, 109-138. Spijker, Jeroen; Zueras, Pilar (2018), “Desigualdades socioeconómicas en salud en la población catalana mayor de 50 años durante la última crisis económica”, Revista Española de Salud Pública, 92, e201811085. Suhrcke, Mark; Stuckler, David (2012), “Will the Recession Be Bad for Our Health? It Depends”, Social Science & Medicine, 74(5), 647-653. Tamayo-Fonseca, Nayara; Nolasco Bonmati, Andreu; Moncho, Joaquin; Pereyra-Zamora, Pamela (2018), “Contribution of the Economic Crisis to the Risk Increase of Poor Mental Health in a Region of Spain”, International Journal of Environmental Research and Public Health, 15(11), 2517. DOI: 10.3390/ijerph15112517 Tapia-Granados, José A. (2014), “La crisis y la salud en España y en Europa: ¿Está aumentando la mortalidad?”, Salud Colectiva, 10(1), 81-91. Terán, José M.; Varea, Carlos; Juárez, Sol; Bernis, Cristina; Bogin, Barry (2018), “Social Disparities in Low Birth Weight among Spanish Mothers During the Economic Crisis (2007-2015)”, Nutrition Hospitalaria: organo official de la Sociedad Española de Nutrición Parental y Enteral, 35(Spec. 5), 129-141. Toffolutti, Verónica; Suhrcke, Marc (2019), “Does Austerity Really Kill?”, Economics & Human Biology, 33, 211-223. Urbanos-Garrido, Rosa; Puig-Junoy, Jaime (2014), “Políticas de austeridad y cambios en las pautas de uso de los servicios sanitarios. Informe SESPAS 2014”, Gaceta Sanitaria, 28(suppl. 1), 81-88.

91 The Great Recession and Health Inequalities in Spain

VV. AA. (2017), “Suicidio, desempleo y recesión económica en España”, Revista de Psiquiatría y Salud Mental, 10(2), 70-77. VV. AA. (2018a), “Spain: Health System Review”, Health Systems in Transition, 20(2). Accessed on 23.11.2018, at http://www.euro.who.int/__data/assets/pdf_file/0008/378620/hit-spain-eng.pdf?ua=1. VV. AA. (2018b), “Trends in Cancer Mortality in Spain: The Influence of the Financial Crisis”, Gaceta Sanitaria, February 13. Accessed on 10.10.2018, at https://www.sciencedirect.com/science/article/pii/S0213911118300050. VV. AA. (2018c), “Trends in Health Inequalities in 27 European Countries”, Proceedings of the National Academy of Sciences of the United States of America, 115(25), 6440-6445. DOI: 10.1073/pnas.1800028115 VV. AA. (2018d), “Trends in Small-for-Gestational Age before and after the Economic Crisis in Spain”, European Journal of Public Health, 28(2), 325-327. Weissman, Robert (2009), “Maniacal Deregulation”, Counterpunch, November 12. Accessed on 16.10.2018, at https://www.counterpunch.org/2009/11/12/maniacal-deregulation/. WHO – World Health Organization (1978), “Declaration of Alma-Ata – International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978”. Accessed on 07.10.2018, at http://www.who.int/publications/almaata_declaration_en.pdf.

92 e-cadernos CES, 31, 2019: 93-115

ELENA CACHÓN GONZÁLEZ

CRISIS, SALUD Y CALIDAD DE VIDA. ALGUNAS EVIDENCIAS EN ESPAÑA Y PORTUGAL

Resumen: Tanto el impacto de la crisis desatada en 2008 como su gestión a través de las políticas de austeridad han tenido un claro efecto en los servicios sanitarios y en la salud, tanto en España como en Portugal. En este artículo se analizan algunas evidencias de este impacto desde una doble perspectiva: los indicadores objetivos relativos a la sanidad y los servicios sanitarios en ambos países, y los indicadores subjetivos sobre calidad de vida relacionada con la sanidad y la salud, y la satisfacción de los individuos con los servicios sanitarios. Los datos muestran que, si bien los indicadores objetivos han mejorado una vez superada la crisis, no ocurre los mismo con los indicadores subjetivos, entre otras razones, porque los determinantes sociales de la salud aún están lejos de superar la crisis. Palabras clave: austeridad, calidad de vida, crisis, salud, satisfacción.

CRISIS, HEALTH AND QUALITY OF LIFE. SOME EVIDENCES FROM SPAIN AND PORTUGAL

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

INTRODUCCIÓN En sociedades más igualitarias, los seres humanos son generalmente más felices y más sanos. Además, cada vez hay más evidencia empírica que demuestra que una mayor igualdad económica beneficia a toda la sociedad, tanto si eres rico como si eres pobre. Más igualdad significa avanzar hacia que todas las personas sean

93 Elena Cachón González recompensadas por el trabajo que realizan y sean atendidas las necesidades que tienen (Dorling, 2017: 9-12). Y esto 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 la evolución de los datos del Índice de Gini para estos países en comparación con la media de la Unión Europea de los 28 (UE 28) (véase Gráfico I).

GRÁFICO I – Índice de Gini (2010-2016)

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

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, y crece 1 punto en España. Ahora bien, si se analiza el valor medio de este indicador en esos años, frente al 30,7 de la UE 28, España alcanza el 34,2, seguido de Portugal, con un 34,1, Grecia con un 34 e Italia con un 32,5, lo que pone de manifiesto que las desigualdades 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 hecho contrastado: las personas con mayor nivel educativo, mayor categoría profesional, o mayores ingresos, tienen tasas más bajas de morbilidad y una esperanza de vida más larga. […] la intensidad de estas desigualdades varía de un lugar a otro, y existen notables diferencias dentro de Europa. (Eikemo et al., 2016: 3)

94 Crisis, salud y calidad de vida. Algunas evidencias en España y Portugal Tal y como demuestran Wilkinson y Pickett (2010: 24), el deterioro de la salud corre en paralelo a las desigualdades económicas, puesto que sus resultados evidencian que los problemas de salud y los problemas sociales son más acuciantes en países con mayor desigualdad de ingresos. Y esta situación es especialmente preocupante en Portugal, que, según Wilkinson y Pickett (2010), ocupa el penúltimo lugar en el ranking de países con 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, los ingresos y la condición laboral los factores determinantes de las desigualdades en salud, es decir, que el componente social es su factor decisivo. Según Eikemo et al. (2008: 566), las personas con menor nivel educativo reportan peor salud, mayores tasas de infecciones y una esperanza de vida menor que aquellas que tienen mayores niveles educativos. Además, ponen de manifiesto que dentro de Europa el impacto de las desigualdades educacionales en la salud varía. Sus resultados apuntan a que en el sur de Europa las desigualdades en salud son mayores que en el resto de países europeos, en línea con estudios como el de Husiman et al. (2003) que concluyen que las menores desigualdades se dan en países como Holanda, Bélgica o Francia, y las mayores en Italia, Grecia y España, o el de Van Doorslaer y Koolman (2004) que apuntan a que en Portugal se dan extensas diferencias en la salud autorreportada en relación con los ingresos. 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 como muestra el Gráfico II, en el que se observan dos hechos diferenciados: el primero, que existen grandes diferencias entre España y Portugal, puesto que en España la población con problemas de salud declarados parece evolucionar en paralelo con los ciclos de la situación macroeconómica, mientras que en Portugal, la situación muestra una tendencia al alza a lo largo de toda la crisis; el segundo, que en ambos países se observa que es la población de los quintiles de ingresos más bajos los que reportan peor salud a lo largo del periodo 2008-2017.

95 Elena Cachón González

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 equivalente total. Se identifican cuatro valores de punto de corte (los llamados puntos de corte del quintil) de ingresos, 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 grupo de quintiles representa el 20 % de la población con el ingreso más bajo (un ingreso menor o igual al primer valor de corte), y el quinto grupo de quintiles representa el 20 % de la población con el ingreso más alto (un ingreso mayor que el cuarto valor de corte). Fuente: elaboración propia a partir de Eurostat (2016).

EL CONTEXTO: LA CRISIS ECONÓMICA La austeridad en Europa fue una opción, una alternativa elegida. Estados Unidos y Japón no optaron por la austeridad para gestionar la crisis, sino por políticas que limitaran el impacto de la crisis financiera en la economía real, el empleo y la calidad de vida. En cambio, en la Unión Europea, la crisis de la deuda sirvió de pretexto para imponer la austeridad fiscal y las políticas de devaluación interna en determinados países, insistiendo en las políticas de oferta, y subestimando el papel de la demanda y de la distribución del ingreso y la justicia social. Las políticas aplicadas en los últimos años, aunque con diferente intensidad dependiendo de los países, tienen dos elementos en común: el ajuste fiscal traducido en la austeridad, y la mejora de la competitividad y del empleo vía reducción de los costes salariales (Schulten y Müller, 2014). En este sentido, la política europea consideró que el papel conjunto de la austeridad y la mejora de la competitividad eran los elementos clave para salir de la crisis, y fueron los salarios el elemento central de ajuste para la mejora de la competitividad nacional en las economías europeas. Así las cosas, las crisis se convirtió en la oportunidad para aprobar reformas estructurales que han afectado esencialmente a asalariados, funcionarios públicos,

96 Crisis, salud y calidad de vida. Algunas evidencias en España y Portugal jubilados y beneficiarios de prestaciones sociales. Se han privatizado los servicios públicos, especialmente en países con mayores dificultades; se han recortado las pensiones, se ha aumentado la edad de jubilación y se han reducido las tasas de reemplazo; además, se ha debilitado la protección de los asalariados a través de la desregulación de sus condiciones laborales y de mayores niveles de flexibilidad laboral, mediante medidas que fortalecen la flexibilidad de los contratos y empleos "atípicos" y la gestión del tiempo de trabajo por parte de los empleadores, que facilitan los despidos y que limitan las prestaciones por desempleo, reduciendo por un lado los subsidios y endureciendo por otro lado las condiciones de acceso (Triantafillou, 2014). Como señala Degryse (2014: 22), a partir de diciembre de 2009, a la crisis de la deuda griega, le siguieron, entre otros países, España y Portugal, y finalmente, toda la Eurozona. En 2010, la Unión Europea anuncia, en coordinación con el Banco Central Europeo y el Fondo Monetario Internacional, un plan de ayuda para Grecia, con una contrapartida: la austeridad exigida por la nueva gobernanza económica europea y el control exhaustivo del déficit. A través de la reforma del Pacto de Estabilidad y Crecimiento, e implementando lo que se conoce como Semestre Europeo (cuyo objetivo inicial era fortalecer la coordinación de las políticas económicas entre los Estados miembros), la Unión Europea aumentó la supervisión de los presupuestos nacionales, con el fin de garantizar la coherencia ex ante entre ellos y con los compromisos adquiridos a nivel europeo. De este modo, los Programas Nacionales de Reformas a partir de 2011 contienen medidas destinadas principalmente a controlar el gasto público y a mejorar su eficiencia, a recortar salarios y pensiones públicas, y a congelar contrataciones en el sector público. En relación con la atención médica, las medidas se centran en reducir el gasto, mediante el establecimiento de mecanismos de control y la limitación de determinados gastos, como los suministros farmacéuticos, entre otros.

EFECTOS DE LA CRISIS ECONÓMICA EN LA SANIDAD En países como Portugal el sector de la sanidad fue inicialmente asolado por las medidas de austeridad, pero a medida que se desarrolló la crisis, se fueron implementando numerosos recortes del gasto en los presupuestos (Gool y Pearson, 2014: 19). Análisis como el de Jiménez-Martín (2014: 33) señalan que “el contraste existente entre la variación del gasto total en sanidad en el periodo 2000-2009 y el periodo 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 la mayoría, si ha habido crecimiento, éste ha sido escaso. En España, el gasto

97 Elena Cachón González sanitario total ha caído un 5 % en el periodo 2009-2012 al igual que Portugal (-4 %), viéndose sólo superado por Grecia (-24 %) e Irlanda (-10 %) justamente el resto de los integrantes del conjunto de países parcial o totalmente rescatados. Sigue de cerca Italia, que siempre estuvo en un tris de ser también rescatada. (ibidem)

Además de la austeridad, y los recortes de gasto público sanitario asociados, la gestión de la crisis económica en la sanidad en Europa se ha caracterizado también por una nueva gestión, traducida en el ahorro de costes y el aumento de la eficiencia en la financiación y la provisión publica de cuidados de salud (Popic et al., 2019: 744). Tanto en España como en Portugal se aplicaron medidas en relación distintos ámbitos sanitarios. Por ejemplo, en cuanto la financiación pública del sistema sanitario, en Portugal se incrementó un 1 por ciento el IVA en determinados medicamentos; en relación con la cobertura sanitaria, en España se redujeron los servicios a los que podía acceder los inmigrantes indocumentados, mientras que en Portugal se excluyeron determinados medicamentos de la cobertura farmacéutica y se aumentaron los costes de los usuarios de algunas vacunas, así como de determinadas medicinas relacionadas con la salud mental. Por otro lado, se revisaron los precios de los fármacos en ambos países con reformas como la reducción del 30 % del precio de los medicamentos genéricos en España, o la investigación de los precios pagados a las farmacéuticas por algunos medicamentos cubiertos por la sanidad pública en Portugal. Pero también se revisaron los “precios” de los trabajadores de la sanidad, o recortando el sueldo de los funcionarios de la sanidad pública en España y Portugal y recortando a la mitad el salario de las horas extras en Portugal. Otras medidas se centraron en la oferta del sistema sanitario, como la reducción del número de camas hospitalarias, tanto en España como en Portugal, o la racionalización de los servicios hospitalarios y los centros de salud (Gool y Pearson, 2014: 21-22). La evidencia muestra que todas estas políticas de austeridad aplicadas en Europa han resultado económicamente ineficientes y socialmente injustas, puesto que han aumentado las desigualdades, especialmente entre los más vulnerables (Triantafillou, 2014). Por ejemplo, en el caso de España, los datos del Decil del Salario Principal derivados del Encuesta de Población Activa ponen de manifiesto que entre 2009 y 2016 el 10 % de los trabajadores con menores retribuciones han sufrido una caída del 14 % en sus salarios reales; el segundo decil ha perdido un 10 % y el tercero, un 8 %. En decir, los trabajadores con menores ingresos son los que han sufrido un mayor ajuste salarial, de modo que aumentan las desigualdades y a la vez las situaciones de pobreza y exclusión social.

98 Crisis, salud y calidad de vida. Algunas evidencias en España y Portugal Según Oliva et al. (2018: 56), en España “algunos problemas de salud […] tienen un gradiente social claro que parece haber aumentado durante la crisis”. Además, los resultados sobre las necesidades médicas no cubiertas ponen de manifiesto un claro gradiente social durante los años analizados (2004-2016), que perjudica a la población económicamente más desfavorecida y que es la más afectada por la crisis. Y continúa concluyendo que

la desigualdad se redujo de forma importante antes del comienzo de la Gran Recesión, entre los años 2004 y 2007, llegando los índices a alcanzar valores positivos en este último año. En 2007 y 2008 el gradiente social deja de ser significativo, pero vuelve a aumentar de forma continuada hasta el año 2014, momento en que esta tendencia comienza a revertirse nuevamente. A partir de 2015, un año después de que se inicie la recuperación económica, la desigualdad deja de ser significativa, retornando a la situación inmediatamente anterior a la crisis. (Oliva et al., 2018: 183)

En esta línea apunta Jiménez-Martín (2014: 10), al señalar que, a pesar de que los indicadores sobre el estado de la salud en España no han sufrido deterioro alguno entre los 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 largo plazo, que

han empeorado sustancialmente en estos años, 3,5 y 4,1 puntos porcentuales, respectivamente […]. En consecuencia, si no se pone remedio rápidamente, dichos aumentos, agravados con las restricciones de acceso a servicios introducidos en 2012, pueden derivar en empeoramientos sustanciales de la salud de los individuos más desfavorecidos. Es decir, puede inducir en un aumento en las inequidades en salud entre la población española. (ibidem: 31- 32)

Los datos no dejan lugar a dudas: tanto en España como en Portugal, el gasto público en cuidados sanitarios (calculado en euros por habitante) está muy lejos de los niveles anteriores a la crisis, tal como muestra el Gráfico III. Como señala Lobato (2011: 97), no existen 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.

99 Elena Cachón González

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

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

Según los datos de Eurostat (2016), España parte de un aumento del gasto en 2008 del 9,3 %, mientras que Portugal se sitúa en el 4,4 %, y aumenta en 2009 hasta el 5,7 %. A partir de ese año, ambos países muestran una tendencia a la baja, que toca fondo en 2012 con caídas del 5,3 % del gasto por habitante en España y del 9% en Portugal. Desde 2013 inician una lenta recuperación, que alcanza los niveles de gasto por habitante de antes 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 la sanidad pública se ha debilitado tanto en España como en Portugal, países ambos con enormes desigualdades, envejecimiento creciente y una peor situación de la salud en comparación con otros países europeos. Recordemos que la crisis en la Unión Europea es en realidad una crisis múltiple. La crisis financiera que estalló en 2007 puso de manifiesto las profundas grietas en la arquitectura de la Unión Económica y Monetaria en Europa, sus defectos de configuración, los desequilibrios existentes y sus insuficiencias estructurales. Y en este contexto, la crisis económica y las políticas aplicadas agravaran esos desequilibrios estructurales existentes en los distintos países, mientras que la recapitalización de los bancos agravó los déficits públicos de distintas economías europeas. Además, la crisis de la deuda en 2010 en Grecia se extendió rápidamente a Irlanda y Portugal primero, y a España e Italia después, y los factores internos específicos en cada país y en cada economía terminaron por dibujar una gestión nacional de la crisis bajo el paraguas de

100 Crisis, salud y calidad de vida. Algunas evidencias en España y Portugal las mismas responsabilidades de la política europea en esa gestión (Triantafillou, 2014). Dado que el desarrollo de las políticas públicas no es neutral, las desigualdades relacionadas con la salud se volvieron prioritarias en los países del sur de Europa a partir de los años 2010-2011, cuando se pusieron de manifiesto los efectos sociales de las políticas de austeridad impuestas por las instituciones europeas e internacionales (Serapioni, 2017: 2). Según Karanikolos et al. (2013: 1327), la crisis en Europa ha planteado grandes amenazas para la salud, por ejemplo, en cuanto al número de suicidios o nuevos brotes de enfermedades infecciosas, puesto que la conjunción de la austeridad fiscal y la debilidad de la protección social tiene como consecuencia el aumento de riesgos para la salud, tanto sociales como individuales. Pero además de los efectos objetivos de la crisis en la sanidad, y tal y como señala Serapioni (2017: 9), las políticas de austeridad han tenido una serie de efectos subjetivos, dado que aumentaron la insatisfacción con las prestaciones sanitarias en todos los países europeos, pero particularmente en Grecia, como resultado del retroceso sin precedentes del gasto público, y en Portugal, reflejo del declive drástico de las prestaciones, pero también fue significativo en España e Italia, dada la contracción tanto en el gasto como en las prestaciones. Esta situación objetiva tiene efectos subjetivos que se manifiestan en las percepciones de 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 la población 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 los recortes. En este sentido, Bartoll et al. (2015: 7-8) apuntan a que en España los niveles de salud autorreportada han mejorado en el periodo 2011-2012, tanto entre los trabajadores ocupados como entre los trabajadores desempleados, si bien la mejora ha sido menor en éstos últimos, pero subrayan que parte de la explicación es que los trabajadores ocupados reportan mejores niveles de salud debido al miedo a ser despedidos en un contexto de desempleo generalizado. Según Eurofound (2014: 65), la puntuación global de satisfacción con la salud en la Unión Europea en 2001 fue de 7,3 puntos (en una escala de 1 a 10), la misma que en 2007, y destaca el hecho de que entre los mayores incrementos en satisfacción con la salud entre 2003 y 2011 se encuentra Portugal, con casi medio punto de mejora en esos años. En este caso, los datos señalan que la calidad percibida de los servicios de salud ha aumentado, 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

101 Elena Cachón González atención a largo plazo ha disminuido, desde los 5,4 en 2011 a los 5,0 en 2016, si bien en Portugal todas las calificaciones de calidad sobre sus servicios públicos están por debajo de las medias europeas. En el caso de España, este informe señala que la calidad percibida de los servicios de salud ha mejorado de 6,3 en 2003 a 7,2 en 2016, situándose por encima de la media europea (6,7 en 2016) solo en este caso, puesto que la valoración del resto de servicios públicos en España es similar. Por otro lado, los datos ponen de manifiesto que existe una relación positiva y significativa entre la calidad percibida de la asistencia sanitaria y la satisfacción con la salud. Además, la calidad percibida de la asistencia sanitaria está directamente relacionada con las instituciones sanitarias. En aquellos sistemas de salud con menores niveles de gasto, menos médicos generales y copagos más altos, el nivel general de satisfacción es menor (Eurofound, 2014: 68; Popic et al., 2019: 744). Y este es el caso del sur de Europa. Según los datos integrados de 2003-2016 de la Encuesta Europea de Calidad de Vida de Eurofound, Portugal muestra un peor comportamiento en todos los indicadores seleccionados respecto a la media europea (véase Tabla I). En España, si bien los indicadores de calidad sobre distintos aspectos relacionados con la sanidad son superiores 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, datos integrados 2003-2016)

UE 28 España Portugal

Servicios sanitarios 6,18 6,81 5,44

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

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

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

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 Satisfacción 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).

102 Crisis, salud y calidad de vida. Algunas evidencias en España y Portugal

EFECTOS DE LA CRISIS ECONÓMICA EN LA SALUD Y LA CALIDAD DE VIDA A pesar de los efectos de la crisis, la satisfacción con la vida en la Unión Europea durante la última década se ha mantenido en un nivel relativamente alto, y superó los 7 puntos sobre 10 en el año 2016, según la última ronda de la Encuesta Europea de Calidad 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 que los indicadores de felicidad. En Portugal, la evolución de la satisfacción con la vida en ese periodo ha mejorado, pero no así la de la felicidad, que sigue su tendencia a la baja. En España y Portugal, el impacto de una mala salud en la satisfacción con la vida es negativo, 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 y 2017, 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, en Portugal, lo que más preocupa a la población es la salud, que empata con la satisfacción con la vida (10,3 %), seguida de la seguridad (9,8 %). Este índice también analiza las desigualdades en el bienestar relacionadas con la salud percibida. Para Portugal, los resultados 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. En ambos casos, las causas apuntan a la peor situación laboral y a los menores niveles salariales y de ingresos. Al explotar los datos de la dimensión salud, los resultados muestran que en España el porcentaje de adultos que declaran tener buena o muy buena 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 la media de la OCDE. En esa dirección apuntan Huijts et al. (2017), quienes señalan que, en Portugal, el 10% de la población reporta mala o muy mala salud, el 20 % reporta limitaciones 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 por enfermedad y el 19 %, síntomas depresivos. En cuanto a los determinantes sociales a los que se exponen los ciudadanos de estos dos países, los datos ponen de manifiesto que el 18,7 % de la población de

1 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 valoraciones sobre el bienestar entre los países de la OCDE y terceros países, sobre la base de once indicadores de bienestar que incluyen los siguientes: vivienda, ingresos, empleo, comunidad, educación, medio ambiente, compromiso cívico, salud, satisfacción con la vida, seguridad y balance vida-trabajo.

103 Elena Cachón González Portugal declara no tener cubiertas sus necesidades de atención sanitaria general, al igual que el 12,4 % de la población en España. En este sentido, según Eurostat,2 en 2016, un 2,5 % de la población en la UE 28 reportó cuidados médicos no cubiertos por razones financieras, listas de espera o distancia elevada para ser atendido. La tendencia en estas necesidades insatisfechas de atención médica no ha sido uniforme a lo largo del tiempo, ya que estas aumentaron entre 2009 y 2014, en línea con la reducción de los recursos financieros destinados al sistema de salud. A pesar de que el porcentaje es menor que en años anteriores, los costes se mantienen como la razón principal. Conviene señalar que solo un 1 % de la población de mayor ingreso reporta esta razón, frente al 5 % del grupo de menor ingreso, y la mayoría son mujeres, mayores y población con menor educación. Pero a pesar de la evolución 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 situación en España, las tendencias son muy diferentes, tal y como se observa en el Gráfico IV. Los datos muestran que la población afectada por las necesidades de cuidados médicos no satisfechas es mucho mayor en Portugal que en España, donde la situación es más favorable que la media europea en todo el periodo. Además, en España el porcentaje de población que declara necesidades no satisfechas no supera el 0,5 % en el peor momento de la crisis, en el año 2013, mientras que en la UE 28 ese porcentaje aumenta 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 (% de población, 2010-2017)

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

2 Statistics Explained – SDG 3 Good Health and Well-Being: Ensure Healthy Lives and Promote Well- 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.

104 Crisis, salud y calidad de vida. Algunas evidencias en España y Portugal Según O’Donnell et al. (2014: 43), los factores principales que afectan a la satisfacción con la vida pueden dividirse en tres grandes bloques: el económico, vía ingresos, educación y empleo; el social, vía relaciones familiares y sociales, valores y medioambiente; y el personal, vía salud física y salud mental. Y es esta última la que apuntan como el factor personal más determinante para la satisfacción de la vida en los análisis de corte transversal, y aparece como el predictor más importante, mucho más que la enfermedad física, el ingreso, el empleo o la situación familiar. Y una de las razones es su extensión social: el 20 % de la población adulta en las economías avanzadas 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 impacto psicológico que financiero. En este punto conviene recordar que, durante la crisis, el efecto más devastador en España fue el desempleo, que llegó a alcanzar 26,1 % de la población activa en España y al 16,4 % en Portugal en el año 2013. En 2017, los datos cerraron con una tasa de paro del 17,2 y 9,0 %, respectivamente. Dicho de otro modo: el desempleo afectó a casi cuatro millones de trabajadores en España y medio millón en Portugal. Según el informe Índice de Bem-Estar 2004-2016 (INE, 2017), en Portugal el bienestar descendió entre los años 2007 y 2012, y a partir de entonces tuvo una evolución más favorable. El indicador de “vulnerabilidad económica”, que refleja la pobreza monetaria y la privación material, tiene la segunda peor evolución. La evolución más desfavorable corresponde al dominio “empleo e ingresos”, debido a la situación del desempleo, al subempleo y a la evolución de los salarios. Además, el informe alerta de que esta situación se intensifica a partir de 2009, y no es hasta 2013 cuando empieza a mostrar un mejor comportamiento. En cuanto al dominio “salud”, y a pesar de que es el componente con la cuarta mejor evolución, ésta fue mucho más positiva en los años anteriores a la crisis que en los posteriores a la misma. Otro de los efectos de la crisis que merece la pena destacar de relación con la salud, es la evolución de la salud mental. Estudios como los de Thomson et al. (2015: 37) o Petmesidou y Guillén (2014: 304) muestran como la crisis aumentó los problemas de salud, sobre todo de salud mental, entre los colectivos menos favorecidos, y especialmente 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 vulnerables son aquellas que están en países donde se producen mayores recortes en el presupuesto público y aparecen tasa de desempleo creciente, porque la conjunción de la pérdida del empleo y el miedo a perderlo tienen efectos adversos para la salud mental, efectos que se han evidenciado en Grecia, España y

105 Elena Cachón González Portugal (Karanikolos et al., 2013: 1328; Urbanos-Garrido y López-Valcárcel, 2015: 182). Como señalan Hemingway et al. (2013: 8), las relaciones entre la recesión económica y las condiciones de la salud mental están más que reconocidas en las investigaciones empíricas, de manera que el desempleo, la pérdida de ingresos, los problemas con la vivienda 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 han sido catastróficos, entro otros, por el aumento de la tasa de suicidios. En esta línea advierten Gool y Pearson (2014: 28), al señalar que cada vez existen más evidencias de que las crisis económicas están fuertemente relacionadas con una peor salud, 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 propios trabajadores desempleados, aumentando la inseguridad entre su familia y su comunidad (Gili et al., 2012: 104). Asimismo, a diferencia de la salud física, los efectos de la recesión económica en la salud mental se manifiestan a corto plazo, de modo que el desempleo, la precariedad laboral o el deterioro de los salarios acontecidos durante estos años de crisis, han afectado a la salud mental de los ciudadanos, aumentando también sus exigencias cognitivas y emocionales relacionadas con el trabajo (Antunes, 2015: 272). En el caso de España, entre los años 2006 y 2010, las personas afectadas por problemas mentales aumentaron significativamente (Sequeira et al., 2015: 72). Además, entre los predictores de una peor salud mental se encuentra el hecho de ser mujer, y conviene recordar que en España el mayor impacto de la crisis se ha dado entre las mujeres, con mayores tasas de desempleo, mayores tasas de empleo parcial, precariedad y menores ingresos (Tamayo-Fonseca et al., 2018: 11). De modo que el impacto de la crisis económica sobre las mujeres se ha visto multiplicado.

REFLEXIONES FINALES Y CONCLUSIONES 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 del individuo”. Tanto es así que los datos de la OCDE (2017) apuntan a que entre los años 2011 y 2017 en España y Portugal es el elemento que más preocupa para tener una buena vida. En este sentido, según Fernández-Mayoralas y Rojo (2005: 122), la calidad de vida es lo que el individuo determina que es importante para su propia vida, de manera que se trata de una percepción individual, pero influenciada por múltiples factores, como las experiencias, las expectativas y las circunstancias personales y sociales, y

106 Crisis, salud y calidad de vida. Algunas evidencias en España y Portugal dado que estos factores pueden variar, la idea de calidad de vida no es estática, sino dinámica. Parece evidente entonces que para valorar la calidad de vida es necesario un enfoque doble y complementario, desde el punto de vista objetivo de “las condiciones y circunstancias 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 las personas, con la satisfacción (subjetiva) que experimentan en relación con esas condiciones de vida, tal y como señalan autores como González-Cabanach et al. (2010: 6). Pero no hay que olvidar, y así lo resumen González-Cabanach et al. (ibidem: 7-9), que cuando se repasan los distintos enfoques metodológicos en relación con el análisis de la calidad de vida, existe un componente social fundamental incorporado en todas las aproximaciones teóricas y metodológicas, que incluye componentes sociales como el sistema económico, las tendencias políticas, el bienestar material, la inclusión social, el estado financiero, el empleo o los ingresos. Los datos son claros al respecto: la crisis ha impactado de lleno en todos y cada uno de estos componentes, tanto en España como en Portugal, y mucho de ellos están lejos de haber mejorado los niveles anteriores a la crisis (véase Tabla II).

TABLA II – Indicadores sociales de riesgo para la salud. Evolución comparada: UE 28, España y Portugal (2008-2016)

Evolución 2008-2013 Evolución 2014-2016 Sentido evolución

UE 28 España Portugal UE 28 España Portugal UE 28 España Portugal

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

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

Riesgo de pobreza y 24,4 26,0 25,6 23,9 28,6 26,4 + - - exclusión social

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

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).

107 Elena Cachón González En este sentido, en el caso de España, alguna de las recomendaciones derivadas de los resultados de Oliva et al. (2018: 211) señalan los determinantes sociales como claves para las políticas públicas en materia de salud, porque existe un empeoramiento de los indicadores generales de riesgo social, y los efectos están siendo heterogéneos entre distintos grupos de población, como las personas más jóvenes, las personas desempleadas o aquellas que tienen empleos más precarios. El informe hace hincapié en un aspecto crucial entre los determinantes sociales de riesgo para la salud, como es el ámbito laboral, que, según sus evidencias, se revela como el marco donde se cronifican los riesgos para la salud. Según Sequeira et al. (2015: 74-75), el impacto de la crisis económica en la salud mental se transfiere a través de cuatro mecanismos: a) el impacto en el nivel de acceso a los cuidados 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 consecuente aumento de depresiones y suicidios; c) el impacto en los cuidados familiares, que dado los menores ingresos, recaen en familiares no cualificados, lo que se traduce en una sobre carga de trabajo para estas personas; y d) el impacto económico y social, lo que interfiere en la productividad y el absentismo. En este sentido, una de las lecciones de la crisis es que la economía, el empleo y sus condicionantes, no solo tienen consecuencias económicas o laborales, sino que tienen efectos directos sobre la salud en general, y sobre la salud mental en particular, de ahí la necesidad de “introducir la salud en todas las políticas y fomentar políticas intersectoriales” (Cortès-Franch y López-Valcárcel, 2014: 5). Y en ese diseño de las políticas públicas, los responsables deben ser conscientes de la importancia de invertir en salud para impulsar la economía (Quaglio et al., 2013: 16). Como apuntan Quaglio et al. (ibidem: 17), los cuidados sanitarios se presentan a menudo y exclusivamente como una fuente de gasto y de consumo de recursos, pero se trata de un sector que contribuye de manera significativa al crecimiento de la economía, dado que representa el 9 % del PIB en la UE 28 y el 10 % del empleo. Y continúan subrayando que los impactos negativos de las crisis sobre la salud pueden evitarse con una protección social adecuada, con la promoción de la sanidad y con una provisión adicional de cuidados sanitarios. Así mismo, más allá de las estrategias generales, laborales y sociales que deban implantarse, es importante desarrollar políticas específicas para aquellos colectivos más expuestos a los efectos de las crisis económicas en cuanto a salud mental se refiere (Córdoba-Doña et al., 2016: 10), porque tener la capacidad de proveer de tratamientos adecuados y efectivos no solo tiene beneficios para la salud de los individuos, sino también para la economía, en relación con unas mejores perspectivas de empleo, tan importantes en mercado de

108 Crisis, salud y calidad de vida. Algunas evidencias en España y Portugal trabajo como el español, pero también de mejores salarios y mayores incrementos de productividad (Gool y Pearson, 2014: 28). Como señalan Cortès-Franch y López-Valcárcel (2014: 2),

el impacto de las crisis económicas en la salud y en las desigualdades en salud depende de distintos factores, como el momento histórico, las características culturales del país, el desarrollo previo de las políticas sociales y, sobre todo, las políticas desarrolladas por los gobiernos para superar esta situación.

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

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

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

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

109 Elena Cachón González 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 del propio Estado de Bienestar. La extensión de opiniones negativas al respecto puede derivar 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 en sanidad. La gobernanza económica europea debe sustituirse por una “gobernanza realmente democrática” (Álvarez Cantalapiedra, 2019: 10), que recupere la dimensión social del proyecto europeo como núcleo central de la política en todas sus dimensiones. Los actuales retos económicos y sociales a los que se enfrentan España y Portugal, pero la Unión Europea en general, en relación con la redefinición de sus políticas sociales, económicas y laborales debe procurar integrar una concepción más amplia del bienestar individual y social de los países, incorporando indicadores objetivos y subjetivos 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 y una serie de reformas de gobernabilidad permitiría una política mucho más coherente centrada en el objetivo general de bienestar, en línea entre otras iniciativas, como los Objetivos de Desarrollo Sostenible o la iniciativa Más allá del PIB de la propia Comisión Europea. Se trata de pensar una política económica orientada hacia el bienestar, la sostenibilidad y la convergencia en Europa, que se centre fundamentalmente en la mejora de la calidad de vida, el empleo decente y una justa distribución del bienestar material, acompañadas de una actividad estable del sector público, la sostenibilidad ambiental y unas relaciones económicas estables y equilibradas para las sociedades, pero también para los individuos.

ELENA CACHÓN GONZÁLEZ Universidad a Distancia de Madrid Vía de Servicio A-6, 15, 28400 Collado Villalba, Madrid, España Contacto: [email protected]

Recibido: 20.02.2019 Aceptación comunicada: 23.06.2019

110 Crisis, salud y calidad de vida. Algunas evidencias en España y Portugal

REFERENCIAS BIBLIOGRÁFICAS Álvarez Cantalapiedra, Santiago (2019), “El desconcierto europeo”, Papeles, 145, 5-11. Consultado el 21.05.2019, en https://www.fuhem.es/2019/10/21/el-desconcierto-europeo-2/. Antunes, José Antonio Pereira de Jesus (2015), “Crise económica, saúde e docença”, Psicologia, Saúde & Doenças, 16(2), 267-277. Consultado el 03.05.2019, en http://www.scielo.mec.pt/pdf/psd/v16n2/v16n2a11.pdf. Bartoll, Xavier; Toffolutti, Veronica; Malmusi, Davide; Palència, Laia; Borrel, Carme; Suhrcke, Marc (2015), “Health and Health Behaviours Before and During the Great Recession, Overall and by Socioeconomic Status, Using Data from Four Repeated Cross-Sectional Health Surveys in Spain (2007-2012)”, BMC Public Health, 15, art. n.º 865. Consultado el 03.05.2019, en https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889- 015-2204-5. Córdoba-Doña, Juan Antonio; Escolar-Pujolar, Antonio; San Sebastián, Miguel; Gustafsson, Per E. (2016), “How are Employed and Unemployed Affected by the Economic Crisis in Spain? Educational Inequalities, Life Conditions and Mental Health in a Context of High Unemployment”, BMC Public Health, 16, art. n.º 267. Consultado el 03.05.2019, en https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-016-2934-z. Cortès-Franch, Imma; López-Valcárcel, Beatriz González (2014), “Crisis económico-financiera y salud en España. Evidencia y perspectivas. Informe SESPAS 2014”, Gaceta Sanitaria, 28(supl. 1), 1-6. Consultado el 12.10.2018, en http://gacetasanitaria.org/es-crisis- economico-financiera-salud-espana-evidencia-articulo-resumen-S0213911114000971. Degryse, Christophe (2014), “The New European Economic Governance”, Working Paper 2012, 14. Brussels: European Trade Union Institute. Dorling, Danny (2017), The Equality Effect. Improving Life for Everyone. Oxford: New Internationalist Publications. Eikemo, Terje; Huijts, Tim; Bambra, Clare; McNamara, Courtney; Stornes Per; Balaj, Mirza (2016), “Desigualdades sociales en salud y sus determinantes: principales resultados de la séptima edición de la Encuesta Social Europea”, European Social Survey, 6. Consultado el 10.10.2018, en https://www.europeansocialsurvey.org/docs/findings/ESS7_toplines_issue_6_health_Spa nish.pdf. Eikemo, Terje A.; Huisman, Martijn; Bambra, Clare; Kunst, Anton E. (2008), “Health Inequalities According to Educational Level in Different Welfare Regimes: A Comparison of 23 European Countries”, Sociology of Health & Illness, 30(4), 565-582. Consultado el 13.10.2018, en https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1467- 9566.2007.01073.x. Eurofound (2014), Third European Quality of Life Survey – Quality of Life in Europe: Trends 2003-2012. Luxembourg: Publications Office of the European Union. Consultado el 09.07.2018, en

111 Elena Cachón González

https://www.eurofound.europa.eu/sites/default/files/ef_publication/field_ef_document/ef13 64en.pdf. Eurofound (2017), European Quality of Life Survey 2016: Quality of Life, Quality of Public Services, and Quality of Society. Luxembourg: Publications Office of the European Union. Consultado el 02.02.2018, en https://www.eurofound.europa.eu/es/publications/report/2017/fourth-european-quality-of- life-survey-overview-report. Eurostat (2016), “Analytical Report on Subjective Well-Being”, Statistical Working Papers, 2016. Consultado el 09.03.2018, en https://ec.europa.eu/eurostat/documents/3888793/7439887/KS-TC-16-005-EN- N.pdf/5e59f7a7-0c81-4122-a72c-bf880f84b4ec. Feigl, Georg (2017), “From Growth to Well-Being: A New Paradigm for EU Economic Governance”, ETUI Working Paper Brief, 2. Consultado el 14.11.2018, en https://www.etui.org/Publications2/Policy-Briefs/European-Economic-Employment-and- Social-Policy/From-growth-to-well-being-a-new-paradigm-for-EU-economic-governance. Fernández-Mayoralas, Gloria; Rojo, Fermina (2005), “Calidad de vida y salud: planteamientos conceptuales y métodos de investigación”, Territoris, 5, 117-135. Gili, Margalida; Roca, Miquel; Basu, Sanjay; McKee, Martin; Stuckler, David (2012), “The Mental Health Risks of Economic Crisis in Spain: Evidence from Primary Care Centres, 2006 and 2010”, European Journal of Public Health, 23(1), 103-108. Consultado el 26.11.2018, en https://academic.oup.com/eurpub/article/23/1/103/465154?searchresult=1. González-Cabanach, Ramón; Valle, Antonio; Arce, Ramón; Fariña, Francisca (2010), Calidad de vida, bienestar y salud. Madrid: Psicoeduca. Gool, Kees; Pearson, Mark (2014), “Health, Austerity and Economic Crisis: Assessing the Short-Term Impact in the OECD Countries”, OECD Health Working Papers, 76. Consultado el 12.12.2018, en https://www.oecd-ilibrary.org/docserver/5jxx71lt1zg6- en.pdf?expires=1558540564&id=id&accname=guest&checksum=32EC205F2702C9AEB E7624A7CB9B9F6A. Hemingway, Steve; Coxon, George; Munday, Dave; Ramsay, Mike (2013), “Austerity is Bad for Mental Health: Implications for Mental Health Nurses”, Mental Health Nursing, 33(6), 7-9. Huijts, Tim; Stornes, Per; Eikemo, Terje A.; Bambra, Clare (2017), “The Social and Behavioural Determinants of Health in Europe: Findings from the European Social Survey (2014) Special Module on the Social Determinants of Health”, European Journal of Public Health, 27(supl. 1), 55-62. Consultado el 05.06.2017, en https://academic.oup.com/eurpub/article/27/suppl_1/55/3045951. Husiman, Martijn; Kunst, Anton; Mackenbach, Johan (2003), “Socioeconomics Inequalities in Morbidity among the Elderly. A European Overview”, Social Science and Medicine, 57, 861-873.

112 Crisis, salud y calidad de vida. Algunas evidencias en España y Portugal

INE – Instituto Nacional de Estatística (2017), Índice de Bem-Estar 2004-2016. Lisboa: INE. Consultado el 17.10.2018, en https://www.ine.pt/ngt_server/attachfileu.jsp?look_parentBoui=313012429&att_display=n &att_download=y. Jiménez-Martín, Sergi; Andrea Viola, Analía (2014), “El sistema de salud en España en perspectiva comparada. Primer Informe Observatorio de Sanidad Fedea”, Observatorio de la Sanidad Fedea. Madrid: Fedea. Consultado el 14.11.2018, en http://sanidad.fedea.net/docs/informe.pdf. Karanikolos, Marina; Mladovsky, Philipa; Cylus, Jonathan; Thomson, Sarah; Basu, Sanjay; Stuckler, David; Mackenbach, Johan; McKee, Martin (2013), “Financial Crisis, Austerity, and Health in Europe”, The Lancet, 381(9874), 1323-1331. Consultado el 17.12.2018, en https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60102-6/fulltext. Lobato, Paula (2011), “Saúde pública e crise: uma reflexão”, Revista Portuguesa de Saúde Pública, 29(2), 97-99. Consultado el 02.01.2019, en https://www.elsevier.es/en-revista- revista-portuguesa-saude-publica-323-pdf-S0870902511700128. OCDE (2017), How’s Life? 2017: Measuring Well-Being. Paris: OECD Publishing. Consultado el 09.03.2018, en https://www.oecd-ilibrary.org/how-s-life- 2017_5jfmdz09cdf2.pdf?itemId=%2Fcontent%2Fpublication%2Fhow_life-2017- en&mimeType=pdf. O´Donnell, Gus; Deaton, Angus; Durand, Martine; Halpern, David; Layard, Richard (2014), Wellbeing and Policy. London: Legatum Institute. Consultado el 12.06.2018, en https://li.com/wp-content/uploads/2019/03/commission-on-wellbeing-and-policy-report- march-2014-pdf.pdf. Oliva, Juan; Peña, Luz; González, Beatriz; Urbanos, Rosa; Barber, Patricia; Zozaya, Néboa (2018), “Informes, Estudios e Investigación 2018 – Crisis económica y salud en España”. Madrid: Ministerio De Sanidad, Consumo y Bienestar Social. Consultado el 01.10.2018, en https://www.mscbs.gob.es/estadEstudios/estadisticas/docs/CRISIS_ECONOMICA_Y_SA LUD.pdf. Petmesidou, Maria; Guillén, Ana M. (2014), “Can the Welfare State as We Know It Survive? A View from the Crisis-Ridden South European Periphery”, South European Social Politics, 19(3), 295-307. Consultado el 12.10.2018, en https://www.tandfonline.com/doi/pdf/10.1080/13608746.2014.950369?needAccess=true. Popic, Tamara; Schneider, Simone; Asensio, María (2019), “Public Opinion on Health Care in the Context of Economic Crisis: Evidence from Portugal”, Journal of Social Policy, 48(4), 741-764. Quaglio, Gianluca; Karapiperis, Theodoros; Van Woensel, Lieve; Arnold, Erika; McDaid, David (2013), “Austerity and Health in Europe”, Health Policy, 113(1-2), 13-19. Ruiz, Miguel; Pardo, Antonio (2005), “Calidad de vida relacionada con la salud: definición y utilización en la práctica médica”, Pharmacoeconomics, 2(1), 31-43.

113 Elena Cachón González

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, art. n.º 45. Consultado el 10.10.2018, en https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5339976/pdf/12939_2017_Article_518.pdf Schulten, Thorsten; Müller, Torsten (2014), “European Economic Governance and Its Intervention in National Wage Development and Collectice Bargaining”, in Steffen Lehndorff (ed.), Divisive Integration: The Triumph of Failed Ideas in Europe – Revisited. Brussels: ETUI, 331-363. Sequeira, Carlos; Sá, Luís; Carvalho, José Carlos; Sampaio, Francisco (2015), “Impacto da crise financeira e social na saúde mental”, Revista Portuguesa de Enfermagem de Saúde Mental, 14, 72-76. Consultado el 12.05.2019, en http://www.scielo.mec.pt/pdf/rpesm/n14/n14a10.pdf. Serapioni, Mauro (2017), “Crise econômica e desigualdades nos sistemas de saúde dos países do Sul da Europa”, Saúde Pública, 33(9), e00170116. Consultado el 01.11.2018, en http://www.scielo.br/pdf/csp/v33n9/1678-4464-csp-33-09-e00170116.pdf. Spijker, Jerone; Gumá, Jordi (2018), “El efecto de la crisis económica sobre la salud en España según el nivel educativo y la relación con la actividad: ¿importa también la duración de la crisis?”, Salud Colectiva, 14(4), 655-670. Tamayo-Fonseca, Nayara; Nolasco, Andreu; Moncho, Joaquín; Barona, Carmen; Irles, María Ángeles; 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 Spain”, International Journal of Environmental Research and Public Health, 15(11), art. n.º 2517. Consultado el 13.05.2019, en https://www.mdpi.com/1660- 4601/15/11/2517. Thomson, Sarah; Figueras, Josep; Evetovits, Tamás; Jowett, Matthew; Mladovsky, Philipa; Maresso, Anna; Cylus, Jonathan; Karanikolos, Marina; Kluge, Hans (2015), Economic Crisis, Health Systems and Health in Europe. Maidenhead: Open University Press. Triantafillou, Christos (2014), “Greece under the Economic Adjustment Programme. Internal Devaluation, Deconstruction of the System of Collective Bargaining and Social Impacts”, The New EU Economic Governance and Its Impact on the National Collective Bargaining Systems. Madrid: Fundación 1º de Mayo, 115-150. Urbanos-Garrido, Rosa; López-Valcárcel, Beatriz (2015), “The Influence of the Economic Crisis on the Association between Unemployment and Health: An Empirical Analysis for Spain”, European Journal of Health Economics, 16(2), 175-184. Consultado el 18.05.2019, en https://www.ncbi.nlm.nih.gov/pubmed/24469909. Van Doorslaer, Eddy; Koolman, Xander (2004), “Explaining the Differences in Income‐Related Health Inequalities across European Countries”, Health Economics, 13(7), 609-628. Consultado el 13.01.2019, en https://onlinelibrary.wiley.com/doi/pdf/10.1002/hec.918.

114 Crisis, salud y calidad de vida. Algunas evidencias en España y Portugal

Wilkinson, Richard; Pickett, Kate (2010), The Spirit Level: Why Greater Equality Makes Societies Stronger. New York: Bloomsbury Press.

115 e-cadernos CES, 31, 2019: 116-146

RAÚL PAYÁ CASTIBLANQUE

CONTEXTO ECONÓMICO Y DETERMINANTES SOCIALES DE LA ACCIDENTABILIDAD LABORAL EN

EL SUR DE EUROPA. LOS CASOS PORTUGUÉS Y ESPAÑOL

Resumen: El modelo neoliberal de gestión de la crisis económica (austeridad, precariedad laboral y recortes en el Estado de Bienestar) ha provocado un aumento de las desigualdades sociales, la desregulación del mercado de trabajo y el debilitamiento de sus principales instituciones (derecho del trabajo, sindicatos y negociación colectiva), operando, asimismo, como factores determinantes del repunte en los índices de accidentes laborales, especialmente en el sur de Europa. Palabras clave: crisis, desigualdades, precariedad, salud laboral, sindicalismo.

ECONOMIC CONTEXT AND SOCIAL DETERMINANTS OF OCCUPATIONAL ACCIDENTABILITY IN

SOUTHERN EUROPE. THE PORTUGUESE AND SPANISH CASES

Abstract: The neoliberal model in the economic crisis management (austerity, job insecurity and cuts in the welfare state) has caused an increase in social inequalities, the deregulation of the labor market and the weakening of its main institutions (labor law, trade unions and collective bargaining), which have beendecisive in the upturn in labor accident rates, especially in southern Europe. Keywords: crisis, inequalities, occupational health, precariousness, trade unionism.

INTRODUCCIÓN Con la caída de Lehman Brothers en 2008 se iniciaba una década de crisis financiera y estancamiento económico a nivel global (a Gran Recesión), que ha sido utilizada por las instituciones internacionales de orientación neoliberal (la Troika formada por la Comisión Europea, el Banco Central y el Fondo Monetario Internacional) para imponer políticas de austeridad económica y desregulación social orientadas a la transformación radical de los mercados de trabajo y de las relaciones laborales (la Gran Agresión), provocando un

116 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España notable incremento de la desigualdad y el debilitamiento de las estructuras y prestaciones del Estado de Bienestar (la Gran Regresión) (Lehndorff, 2015). En los Estados del sur de Europa, la Troika impuso duros programas de desregulación y flexibilización de las condiciones de trabajo con objeto de hacer frente a la deuda pública y mejorar, supuestamente, el dinamismo y posicionamiento de los mercados nacionales en una economía global. La reforma del Código do Trabalho en Portugal (Lei n.º 23/2012, de 25 de junho) y la del Estatuto de los Trabajadores en España (Real Decreto-ley 3/2012, de 10 de febrero) fomentaron un espectacular crecimiento del trabajo atípico (contratación temporal, de duración determinada y trabajo no declarado), 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, el debilitamiento de las instituciones y recursos del poder sindical (Costa, 2012; Leite et al., 2014; Alós et al., 2017). A los efectos de nuestra investigación, cabe señalar que la precariedad laboral impuesta opera negativamente en dos sentidos. En primer lugar, pone en peligro el Estado de Bienestar, en la medida que el sistema de protección (asistencia sanitaria y prestaciones sociales) se financia en la mayoría de los países europeos a través de las aportaciones de los/las empresarios/as y trabajadores/as por el rendimiento del trabajo. En consecuencia, las medidas de austeridad reducen los ingresos estatales, que dependen en gran medida de políticas de pleno empleo y salarios decentes, provocando fuertes recortes en gasto público sanitario y otros de índole social (Benavides et al., 2018). En segundo lugar, dichas políticas impactan negativamente en los estándares de salud laboral, en la medida que la contratación temporal opera como un elemento diferencial en 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, las altas tasas de desempleo erosionan el poder de negociación de los trabajadores y sus organizaciones de clase, retroalimentando la espiral de desregulación y deterioro de las condiciones de trabajo y salud laboral (Arocena Garro y Núñez Aldaz, 2005), consideradas, en el discurso legitimador del capitalismo neoliberal, como una especie de “peaje” o “daño colateral” para la salida de la crisis económica (Terrés et al., 2004). En este punto, los datos oficiales registrados por Eurostat sobre la distribución y evolución reciente del índice de incidencia por accidentes de trabajo estandarizados (número de accidentes por cada 100 000 personas trabajadoras con cuatro o más días de baja laboral) permiten constatar que son los países periféricos del sur de Europa –

117 Raúl Payá Castiblanque salvo el caso de Italia que por sus condiciones particulares que analizaremos posteriormente –, los que presentan una mayor accidentabilidad (ver Gráfica I), doblando incluso la media comunitaria que registra, además, una evolución positiva.

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 los empleados que no están asegurados por la Social Insurance Foundation (IKA, en el acrónimo griego) y que suponen alrededor del 60- 70 % de los trabajadores, por lo que los datos resultantes no acreditan la fiabilidad y homogeneidad necesarias para su utilización en estudios comparados.

Fuente: Elaboración propia a partir de Eurostat (s. d.).

Así las cosas, la hipótesis que nos planteamos como eje vertebrador de nuestra investigación es que el efecto combinado de la agresiva desregulación del mercado de trabajo y de las relaciones laborales en los países europeos periféricos, con el consiguiente aumento de la precariedad contractual, debilitamiento de las instituciones de participación y representación de los/as trabajadores/as y la reducción de la cobertura y eficacia de la negociación colectiva, estaría operando como factor determinante de los

118 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España elevados índices de incidencia de la siniestralidad laboral, así como de su evolución reciente. A tal efecto analizaremos, en primer lugar, la evolución y distribución de los principales indicadores 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).

1. CRISIS ECONÓMICA, PRECARIEDAD LABORAL Y ACCIDENTABILIDAD El modelo de crecimiento económico de los países del sur de Europa se centra, en gran medida, en sectores que aportan bajo valor añadido y un uso intensivo de mano de obra poco cualificada, lo que puede explicar el impacto diferencial que ha tenido sobre los indicadores 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 and citizenship (%). 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.

1 La precariedad laboral tienes múltiples dimensiones, entre otros, el trabajo no declarado e informal, sin embargo, para realizar análisis estadísticos comparados, solo se disponen datos cuantitativos sobre algunas de las principales dimensiones de la precariedad (contratación temporal, antigüedad, segmentación).

119 Raúl Payá Castiblanque En efecto, tal y como podemos observar en la Gráfica II, mientras que Italia y Francia se encuentra en torno a la media de la Unión Europea (UE), las medidas de flexibilización llevadas a cabo por las reformas laborales de 2012 en España, y en menor medida Portugal, han derivado en elevadas tasas de temporalidad y desempleo, llegando a doblar la media europea en el caso español (Alós et al., 2017), por lo que centraremos en ambos países nuestro análisis del impacto de dichas medidas sobre los accidentes de trabajo, según características de la empresa (sector de actividad y tamaño del centro de trabajo) y de los trabajadores (sexo, edad, situación profesional, tipo de contrato y antigüedad) en el periodo comprendido entre el inicio de las reformas laborales (2012) y el de los últimos datos disponibles en materia de siniestralidad (2016). A tal efecto, se han realizado diversas operaciones estadísticas, transformando, en primer lugar, los datos absolutos de los accidentes totales en índices de incidencia (n.º de 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 las operaciones, se han utilizado los datos correspondientes al número de accidentes del Gabinete de Estratégia e Planeamento (GEP/MTSSS)2 para Portugal y las estadísticas de accidentes 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 personas expuestas, se ha extraído de la Encuesta de Población Activa (EPA)4 de cada país. Para analizar las probabilidades de sufrir accidentes de trabajo por parte de los diferentes colectivos, se ha procedido al cálculo del riesgo relativo (en adelante RR), con un intervalo de confianza del 95 % (en adelante IC95 %), comúnmente utilizado en estudios epidemiológicos de salud pública, lo que nos proporciona información sobre el grado de asociación estadística de sufrir accidentes de trabajo entre un colectivo respecto a un grupo de control. De esta manera si el RR resultante es superior a 1, el colectivo 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 un nivel de confianza del 95 %. En este sentido el RR de sufrir accidentes de un grupo de personas trabajadoras frente a otro colectivo de control será significativa cuando entre el IC inferior y superior no se encuentra comprendido el valor número uno.

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, en http://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=t ab2; EPA España. Consultado el 18.12.2018, en https://www.ine.es/prensa/epa_prensa.htm.

120 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España

1.1. ACCIDENTES DE TRABAJO SEGÚN CARACTERÍSTICAS DE LA EMPRESA La Tabla I registra las desigualdades intersectoriales de los índices de incidencia por accidentes de trabajo, tanto en Portugal como en España, en la medida que el sector secundario, y más concretamente el de la construcción para el caso español, doblan prácticamente las respectivas medias nacionales, siendo máximas las diferencias en 2016 (RR= 2,07; IC95 % 1,99-2,15). Tales resultados no hacen sino confirmar la hipótesis de estudios anteriores, en la medida que en los países mediterráneos la especialización productiva en sectores precarios e intensivos en mano de obra constituye un factor explicativo de los elevados índices 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 también con 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 nula regulación legal y cualificación profesional) (Lima, 2004: 5). 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 mayor probabilidad de sufrir accidentes de trabajo, presentando las máximas diferencias en 2014 (RR= 1,28; IC95 % 1,23-1,33), mientras que en España se producen más accidentes en 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 tienen una 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). Sin embargo, las empresas más pequeñas (de 1 a 9 personas) en España se encuentran por debajo de la media, lo que podría ser explicado por la infranotificación de accidentes de trabajo derivada de la débil o inexistente representación sindical que luche por la notificación y registro de los accidentes de trabajo (Eaton y Nocerino, 2000). Estudios previos han identificado una combinación de factores determinantes que vendrían a explicar la mayor siniestralidad laboral en las pymes, que presentan menores índices de gestión preventiva (Walters, 2004: 171; Naroki, 1997: 163), en función tanto de variables cuantitativas –falta de recursos humanos y materiales– como cualitativa –cultura familiar, patriarcal y autoritaria– y de representación (Alós et al., 2013: 1073-1075) que limitan la capacidad de defensa y reivindicación de sus trabajadores (Lima, 2015: 195). En definitiva, la especialización productiva en sectores intensivos en mano de obra y la fragmentación empresarial, derivadas de la creciente dinámica de las economías globales

121 Raúl Payá Castiblanque hacia la subcontratación a empresas cada vez más pequeñas,5 y con peores condiciones de trabajo, operan como factores determinantes de los índices de accidentes 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 y tamaño de empresa en Portugal y España (2012-2016)

Portugal España Año II* RR** (95 %)*** II* RR** (95 %)*** 2012 4.258,1 1 2.948,9 1 2013 4.415,5 1 3.009,2 1 Total 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 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) Agrario 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) 2012 7.339,3 1,67 (1,61-1,74) 4.652,0 1,55 (1,48-1,62) Industria 2013 7.823,7 1,72 (1,66-1,78) 4.590,7 1,50 (1,44-1,57) [Sector 2014 7.956,5 1,70 (1,64-1,73) 4.781,2 1,51 (1,45-1,58) Secundario para Portugal] 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) 2012 - - 6.296,9 2,07 (1,98-2,16) 2013 - - 6.024,1 1,94 (1,86-2,03) Construcción 2014 - - 6.314,7 1,97 (1,89-2,05) 2015 - - 6.794,5 2,02 (1,94-2,10) 2016 - - 7.217,2 2,07 (1,99-2,15) 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) Servicios 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)

5 Según Monjardino et al. (2017: 7) en Portugal “El 97% de las empresas son de 10 o menos trabajadores, las cuales concentran al 29% de los trabajadores, si bien 773 (0,1% del total) de empresas de más de 250 trabajadores concentran un 26% de los trabajadores”.

122 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España

Tamaño de centro de trabajo 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) 1 a 9 2014 5.859,8 1,28 (1,23-1,33) 2.210,7 0,72 (0,68-0,76) trabajadores/as 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) 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) 10 a 49 2014 4.563,3 1,01 (0,97-1,05) 3.746,8 1,20 (1,14-1,25) trabajadores/as 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) 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) 50 o más 2014 3.890,2 0,87 (0,83-0,90) 2.497,0 0,81 (0,77-0,85) trabajadores/as 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 de incidencia 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 de España y EPA de ambos países. Cálculos y elaboración propia.

1.2. ACCIDENTES DE TRABAJO SEGÚN CARACTERÍSTICAS DE LOS/AS TRABAJADORES/AS Si analizamos los índices de incidencia de los accidentes de trabajo por sexo (Tabla II) se puede observar cómo los hombres presentan, en ambos países, el doble de probabilidades 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 en salud laboral puestas de manifiesto por las estadísticas oficiales podrían estar invisibilizando enfermedades no registradas que afectan con mayor prevalencia a las mujeres trabajadoras.

123 Raúl Payá Castiblanque

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

Portugal Año 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 de España y EPA de ambos países. Cálculos y elaboración propia.

Las políticas de desregulación y precarización de las condiciones de empleo y trabajo impuestas han derivado en un aumento de las patologías psicosociales (estrés, depresión, nerviosismo, problemas de sueño, etc.) (EU-OSHA, 2010). Diferentes investigaciones han puesto de manifiesto que el efecto combinado de la división sexual del trabajo, los roles familiares y las peores condiciones de trabajo hacen que las mujeres trabajadoras sufran con mayor prevalencia estos riesgos psicosociales (Artazcoz et al., 2011; Arcas et al., 2013). Sin embargo, estas patologías no se encuentran reconocidas legalmente como enfermedades profesionales en la mayoría de los países de la UE, estimándose para el caso español que “si se añadieran a las bajas por enfermedades profesionales reconocidas los aproximadamente 400.000 casos anuales de bajas por contingencia común provocadas por causas psicológicas o psiquiátricas, la cifra total aumentaría en casi un 40 %” (Sánchez y Conde, 2008: 287), lo que prodría llegar a suponer una discriminación indirecta hacia las mujeres trabajadores en la medida que sufren con mayor intensidad estas patologías laborales. Por lo que refiere a la edad de las personas trabajadoras también se constatan desigualdades en materia de salud laboral (Lima, 2015: 191). Mientras que los/as más jóvenes entre 15 y 24 años presentan mayor probabilidad de sufrir accidentes de trabajo 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 o más

124 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España 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). Tales diferencias se explicarían no tanto por factores sectoriales (mayor o menor concentración de trabajadores en actividades de riesgo) sino por los de carácter estructural (desigual impacto de la crisis y el paro) y contractual (precariedad, temporalidad). Respecto del primer caso, la encuesta de población activa española permite identificar que la tasa de empleo en la construcción para trabajadores/as de 50 a 64 años fue del 5,8 % en 2012 y del 6 % en 2016, mientras que para los de 16 a 24 años fue del 5,4 % al 3,1 % respectivamente; diferencia que se mantiene en la industria manufacturera 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. En cuanto al desigual impacto de la crisis económica sobre el desempleo y la precariedad contractual, la encuesta de población activa de ambos países sitúan el nivel de desempleo de los/las jóvenes (34,2 % en 2012 y 26,16 % en 2016 para trabajadores/as de 20 a 24 años en Portugal y del 48,8 % al 41,4 % respectivamente, en España) muy por encima 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 de precariedad, 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 ambos países y del 7,4 % en 2016 para Portugal y del 8,8 % en España. Así pues, la débil posición de las personas más jóvenes en el mercado de trabajo hace que se vean obligados a aceptar condiciones precarias y, en consecuencia, susceptibles de sufrir más accidentes de trabajo (ver Tabla III) (Terrés et al., 2004; Arocena Garro y Núñez Aldaz, 2005).

125 Raúl Payá Castiblanque

TABLA III – Índice de Incidencia de accidentes totales y Riesgo Relativo por edad en Portugal y España (2012-2016)

Portugal España Edad Año II* RR** (95 %)*** II* RR** (95 %)*** 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) De 15 a 24 años De 16 a 24 años 2014 6.946,0 1,50 (1,45-1,56) 3.239,6 1,04 (0,99-1,09) en España 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) 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) De 25 a 34 años 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) 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) De 35 a 44 años 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) 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) De 45 a 54 años 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) 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) 55 o más años 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) 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 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 de España y EPA de ambos países. Cálculos y elaboración propia.

1.3. ACCIDENTES DE TRABAJO SEGÚN SITUACIÓN PROFESIONAL Y TIPO DE CONTRATO Por lo que refiere a las desigualdades de salud entre clases sociales, los análisis estadísticos realizados sobre la erosión del Estado de Bienestar por Stuckler et al. concluyeron que “la rápida privatización masiva como estrategia de transición económica fue un determinante crucial de las diferencias en las tendencias de mortalidad de adultos” (Stuckler et al., 2009: 399; traducción propia). Esta situación, podría quedar también

126 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España reflejada en las estadísticas de salud laboral puesto que los/as trabajadores/as por cuenta ajena en el caso portugués llegan a quintuplicar las probabilidades de sufrir accidentes de trabajo con respecto a los/las propietarios/as de los medios de producción (RR= 5,73; IC95 % 5,33-6,15; en 2012), siendo también significativa 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 español podría haber producido un efecto similar a la privatización de los servicios públicos de salud en la medida que la probabilidad de sufrir accidentes de trabajo entre empresarios/as y trabajadores/as aumentó desde un (RR= 1,21; IC95 % 1,14-1,28) en 2012 hasta un (RR= 1,54; IC95 % 1,45-1,62) en 2016, mientras que en Portugal las prevalencias no presentaron una tendencia temporal lineal.

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

Portugal

Año II* Trabajador/a por II* Trabajador/a RR** (95 %)*** Cuenta Ajena Autónomo/a y/o Empresario/a 2012 5.147,2 862,3 5,73 (5,33-6,15) 2013 5.313,2 1.036,6 4,92 (4,60-5,25) 2014 5.054,9 1.991,1 2,46 (2,34-2,59) 2015 4.628,4 1.747,3 2,58 (2,44-2,72) 2016 4.866,3 1.481,1 3,18 (3,00-3,37)

España

2012 2.764,4 2.277,3 1,21 (1,14-1,28) 2013 2.774,2 2.241,1 1,23 (1,17-1,30) 2014 2.840,2 2.220,5 1,27 (1,20-1,34) 2015 3.076,1 2.025,9 1,50 (1,42-1,59) 2016 3.099,4 1.995,6 1,54 (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/o empresarios/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 de España y EPA de ambos países. Cálculos y elaboración propia.

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

127 Raúl Payá Castiblanque

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

II* Temporal II* Indefinido RR** (95 %)*** Año 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) 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/as trabajadores/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 y elaboración propia.

Los resultados obtenidos muestran cómo la modalidad contractual es un factor determinante de las desigualdades en salud laboral en la medida que las personas contratadas temporalmente refieren mayor número de accidentes de trabajo, tanto para 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 los análisis de estudios previos (Boix et al., 1997; Benavides et al., 2006), según los cuales las políticas neoliberales de flexibilización estarían impactando negativamente sobre la salud de las personas trabajadoras, en especial en España y Portugal que presentan índices de temporalidad elevados (ver Gráfica II).

128 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España

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

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

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 de referencia. **** IC95 %= Intervalo de confianza del riesgo relativo del 95 %.

Fuente: Anuario de Estadísticas del Ministerio de Empleo y Seguridad Social y EPA. Cálculos y elaboración propia.

La precariedad laboral en España ha llegado a ser de tal magnitud que la contratación temporal es cada vez de menor duración (50,6 días de media en 2017) afectando negativamente a la salud de las personas trabajadoras (Payá y Beneyto, 2018a). Los resultados aportados en el curso de nuestra investigación (Tabla VI) muestran una relación 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 de accidentes 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 los graves (RR= 2,24; IC95 % 2,03-2,47, para 2016) y mortales (RR=1,89; IC95 % 1,45-

129 Raúl Payá Castiblanque 2,47), llegando a triplicarse ampliamente cuando se compara con las personas con 3 o más años de antigüedad en el centro de trabajo. En conclusión, la fragilidad del mercado laboral junto a las políticas neoliberales de flexibilización han afectado gravemente a la salud de las personas trabajadoras operando como factores determinantes de los elevados índices de accidentes laborales en los países del sur de Europa, poniendo de manifiesto, asimismo, las múltiples desigualdades de salud entre clases sociales, identificadas importantes diferencias entre empresarios/as y asalariados/as; trabajadores/as jóvenes y mayores; temporales y indefinidos, entre personal inexperto y los de mayor antigüedad, agravado todo ello por la discriminación indirecta por cuestión de género.

2. IMPACTO Y LÍMITES DE LA LUCHA SINDICAL EN SALUD LABORAL

2.1. IMPACTO Observado las desigualdades sociales, consideramos que la salud laboral no puede verse únicamente desde un punto de vista tecnocrático y pretendidamente objetivo derivado de criterios prefijados por los profesionales de la prevención de riesgos laborales, sino que 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 y de trabajo:

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

Desde un punto de vista histórico, consideramos que dos hitos representan la lucha obrera 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 el siglo XIX y principios del XX, responsable del saturnismo que padecían millones de pintores. La fabricación de la céruse fue muy importante para la economía de Francia que aglutinaba en la región de Lille la mayor parte de la producción europea. Desde mediados del siglo XIX los higienistas ya conocían que el blanco de plomo provocaba graves problemas de salud y, además, se podía sustituir fácilmente por el inofensivo óxido de zinc pero, sin embargo, era mucho más caro que la céruse, por lo que los/as grandes patrones/as de Lille con objeto de preservar su lobby presionaron al gobierno y medios de

130 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España comunicación. El gobierno francés no se planteó prohibir de manera definitiva el uso de la céruse hasta la intervención de la Unión Sindical de Pintores de la Confederación General del Trabajo (CGT), que provocó grandes huelgas durante tres semanas (desde el 13 de marzo hasta el 3 de abril 1906), con el paro de doscientas cuarenta empresas de pintura en Lille y la participación de más de mil pintores/as, la mayoría sindicados/as, lo que obligó a la aprobación del decreto que prohibía la utilización del plomo blanco para la fabricación de pinturas (Rainhorn, 2010). El segundo hito histórico de la lucha sindical en defensa de la salud de los/as trabajadores/as fue la utilización a partir de 1830 del fósforo blanco para la elaboración de 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 tasas de mortalidad que producía el que denominaban comúnmente “veneno blanco”, y en 1844, se descubrió el fósforo rojo que realizaba la misma función pero sin producir daños para la salud. Sin embargo, los/as empresarios/as defendían el fósforo blanco porque los/las clientes lo preferían al ser más fáciles de encender, por lo que, al igual que en el caso de la céruse, presionaron y consiguieron retrasar en más de 40 años su prohibición. En este periodo cabe destacar las huelgas de las fábricas de cerillas Bryantand May en 1888 en Londres como un movimiento clave en la lucha contra el fósforo blanco y, a su vez, muchos/as historiadores/as lo consideraron la génesis de la independencia política de la clase obrera británica (Vogel, 2016a). Estos dos episodios ponen de manifiesto que la salud laboral no es una simple variable tecnocrática objetiva, y que la lucha sindical ha tenido y tiene un papel fundamental en la defensa de los derechos a la seguridad y salud de los/as trabajadores/as en el ejercicio de su actividad. En la actualidad, con la aprobación de la Directiva Marco 89/391-CEE de 1989, relativa a la 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 transposición para todos los estados pertenecientes a la UE, se reconoce, en su artículo 11.3, el derecho de los/as trabajadores/as a ser informados/as, consultados/as y a participar a través de representantes especializados/as (delegados/as de prevención o comités de salud laboral, según la configuración de cada país) en la gestión de la prevención de riesgos laborales en la empresa (Benavides et al., 2018). Así pues, dicha directiva crea un nuevo órgano de representación especializado complementario e incluso superpuesto a los tradicionales de carácter general (unitaria y/o sindical) (Payá, 2014). Diversas investigaciones econométricas llevadas a cabo en diferentes sistemas y contextos 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

131 Raúl Payá Castiblanque et al., 2015; Payá y Beneyto, 2018a), han puesto de manifiesto que en aquellos centros de trabajo en los que hay representantes especializados/as, se logra implementar niveles y estándares más elevados de gestión preventiva. Es decir, las empresas que cuentan con delegados/as de prevención tienen mayor probabilidad de que se evalúen los riesgos y se planifiquen acciones de prevención para eliminarlos. Además, también ha quedado acreditado en numerosas investigaciones que la presencia de 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, habría que añadir que estudios comparados han identificado que los Estados que cuentan con una mayor fortaleza sindical presentan una tasa de accidentes de trabajo menor (Rueda, 2004; Payá y Beneyto, 2018b).

2.2. LÍMITES A LA INTERVENCIÓN SINDICAL Constatado el impacto positivo de la acción sindical sobre la salud laboral, consideramos que, además de los factores contextuales y modalidades contractuales que condicionan la evolución de la accidentabilidad laboral vistos en el primer apartado, las políticas neoliberales también han erosionado los recursos de poder sindical de los países del sur de Europa y, por tanto, devienen como un factor explicativo de la elevada tasa de accidentes de trabajo, por lo que nos centrarnos ahora en su análisis y evaluación (Payá y Beneyto, 2018b; Vogel, 2016). Para ello, en primer lugar, es necesario identificar los recursos de poder sindical. En este sentido, Gumbrell-McCormick y Hyman (2013: 30-31) enumeran y sintetizan los distintos recursos de poder sindical que cuentan con amplio reconocimiento internacional, pudiéndose diferenciar entre: a) el poder estructural (posición y poder de negociación de los/as trabajadores/as en el mercado de trabajo); b) el poder asociativo, 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 de trabajo) (Beneyto, 2017); c) el poder institucional (acuerdos institucionales fruto de la concertación y/o dialogo social y la negociación colectiva) y, por último, d) el poder social o societal, que puede dividirse entre el poder discursivo y colaborativo, del que no nos ocupamos en este artículo por ocuparse de problemáticas (relaciones entre sindicatos y nuevos movimientos sociales) que exceden los objetivos de nuestra investigación y han sido analizadas en profundidad por otros autores (Fonseca y Estanque, 2018; Beneyto, 2017).

2.2.1. EROSIÓN DEL PODER ASOCIATIVO EN SALUD LABORAL 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

132 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España la representación general (unitaria y sindical) como de la especializada (delegados/as de prevención y comités de salud laboral). Del análisis de regresión lineal realizado sobre ambas series de datos (Gráfica III) se pueden extraer varias conclusiones.

GRAFICA 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.

En primer lugar, que existe una correlación positiva entre dichos sistemas de representación (R2= 0,540; p<0.000), por lo que aquellos países con mayor densidad de afiliación sindical también presentan una mayor tasa de representación especializada en salud laboral, debido a que en la mayoría de los casos los/las delegados/as de prevención son elegidos/as por la representación sindical (Payá, 2014). En segundo lugar, se observa como prácticamente la mitad de las empresas de EU-28 tiene representación tanto general como especializada, pero sin embargo, existe una elevada heterogeneidad: mientras que los países del sistema escandinavo presentan una cobertura representativa en torno al 80 % de los centros de trabajo y los del área germánica o centro europea próximos a la media, los países del área oriental y sur de Europa registran, en términos generales, resultados muy por debajo de la media, lo que podría explicar en parte, tal y como manifestaban los estudios previos, la elevada tasa de accidentes de trabajo de los países del sur.

133 Raúl Payá Castiblanque Diferentes características estructurales (históricas y culturales) y coyunturales (regulación legal, mercado laboral y ciclo económico) podrían explicar la heterogeneidad del poder asociativo entre los países europeos. En referencia a las primeras características, diferentes estudios comparados de los sistemas de relaciones laborales (Crouch, 2017; Lehndorff et al., 2017) ponen de manifiesto que los países del sistema escandinavo presentan elevada cobertura representativa derivada, entre otras causas, de su tradición socialdemócrata, una cultura de cooperación entre capital y trabajo proyectada a través de la concertación social tripartita y la implementación del sistema Ghent, en el que los sindicatos participan institucionalmente en la gestión de las prestaciones por desempleo. Por el contrario, el sistema de relaciones laborales del sur de Europa, se ha caracterizado históricamente por una mayor conflictividad entre capital y trabajo, mayor intervención estatal en la regulación de las normas de empleo y la extensión erga omnes (eficacia general) de los convenios colectivos, lo que activa el efecto free rider, desincentivando la afiliación sindical y explicando, en cierta medida, el bajo poder asociativo (niveles de afiliación del 19,2 % de media en los países del sur, oscilando entre el 7,7 % de Francia y el 37,3 % de Italia). Sin embargo, dicho sistema garantiza, por otro lado, un elevado poder institucional, puesto que la eficacia general de los convenios colectivos estatales y sectoriales negociados por los sindicatos más representativos se aplica a todas las personas trabajadoras, garantizando una cobertura de la negociación colectiva próxima al 80 %. Por lo que refiere a las características coyunturales, la flexibilización y desregulación de las condiciones de trabajo no solo ha impactado directamente sobre la salud de las personas, sino que también lo ha hecho indirectamente, puesto que, las políticas neoliberales han debilitado los recursos de intervención de los sindicatos en la medida que erosionan el poder estructural y este a su vez el poder asociativo. Así pues, es conocido que altas tasas de desempleo, de rotación y temporalidad de los/as trabajadores/as limitan su capacidad de negociación (poder estructural), siendo este uno de los principales motivos de desafiliación (poder asociativo), debilitando con ello la capacidad de presión sindical en los centros de trabajo en defensa, entre otras reivindicaciones, de las relacionadas con la salud laboral y la prevención de riesgos (Alós et al., 2013). De hecho, al comparar los datos registrados de las dos Encuestas Europeas de Empresas sobre Riesgos Nuevos y Emergentes (ESENER-1) realizadas en 2009 (EU- OSHA, 2009) y ESENER-2 en 2014 (EU-OSHA, 2014) sobre la tasa de representación especializada en salud laboral (Gráfica IV), se observa una reducción de la cobertura de delegados/as de prevención, que paso de una tasa media europea del 64,6 % en el 2009

134 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España al 58 % en 2014, registrándose un descenso generalizado del nivel de cobertura, siendo muy significativo 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 de trabajo español y la consiguiente erosión de los recursos de intervención sindical.

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.

El efecto combinado del reducido poder asociativo de la representación general y especializada del sistema mediterraneo de relaciones laborales junto a la erosión y desregulación de las condiciones de trabajo, ha hecho que Francia y Portugal como también Grecia, registren la tasa más baja de delegados/as de prevención situándose en un 25 %, 24 % y 17 % respectivamente, muy lejos de la media europea situada en un 58 %. El tamaño de la empresa es, también, un factor determinante, tanto a nivel de representatividad, siendo menor en las pymes que en las grandes empresas (Alós et al., 2013) como a nivel cualitativo, puesto que disponenmenos recursos materiales y humanos para gestionar la salud laboral (Walters, 2004), y la existencia de una cultura paternalista y autoritaria impide la participación sindical (Narocki, 1997), lo que vendría a explicar la mayor tasa de accidentes de trabajo en las pymes (ver Tabla I). En términos de cobertura de la representación especializada, al igual que la representación general, la mayoría de los países de Europa establecen, por transposición a sus legislaciones nacionales de la Directiva Marco 89/391-CEE, umbrales mínimos de trabajadores/as para poder realizar elecciones de órganos de representación especializados (Payá, 2014). Así, la Ley 102/2009, de 10 de Septiembre sobre el

135 Raúl Payá Castiblanque Régimen Jurídico da Promoción de la Seguridad y Salud en el Trabajo (en adelante LPSST) de Portugal o la Ley 31/1995, de 8 de noviembre, de Prevención de Riesgos Laborales (en adelante LPRL) de España, fijan el número de representantes especializados 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, en España 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 Portugal y España

Portugal España

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

A todo ello, cabría añadir, que la configuración española socava las posibilidades de representación en las empresas más pequeñas puesto que recaerá sobre la misma persona las competencias de la representación general y la específica en salud laboral, acumulando ambas funciones ya que estos últimos son elegidos por y entre la representación general. Sin embargo, la ley no amplia el crédito de horas de representación más allá de las atribuidas al sistema general (art. 37.1 de la LPRL) salvo que se disponga por negociación colectiva (Disposición transitoria primera de la LPRL), mientras que la normativa portuguesa, otorga cinco horas al mes exclusivas para la defensa de los intereses específicos en salud laboral (art. 21.7 de la LPSST). Así las cosas, la configuración legal de los órganos de representación especializados en salud laboral vendría a explicar la desigual cobertura entre las empresas más pequeñas y las de mayor tamaño tanto para los países del sur como para la media europea, salvo Italia, por las particularidades que a continuación analizamos (Gráfica V).

136 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España

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 COMO RECURSO

DE PODER ASOCIATIVO EN SALUD LABORAL El caso italiano merece un análisis pormenorizado por cuanto que, a diferencia del resto de países del sur, presenta una densidad de delegados de prevención del 88 % (ver Gráfica IV) situándose como el país europeo con mayor cobertura en la materia, por delante incluso de los países del área escandinava, lo que podría explicar en cierta medida su menor tasa de accidentes de trabajo (ver Gráfica I). Sin embargo, es uno de los pocos países en los que la representación general y especializada no correlaciona puesto que la tasa de afiliación sindical (presencia) se sitúa en torno al 37 %. 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 importante impacto en el cambio del enfoque tradicional de la seguridad y salud laboral de toda Europa. Dicho modelo se caracterizó por una fuerte lucha sindical y movilizaciones masivas en defensa de la salud en el trabajo bajo dos principios. El primero “la salud no se vende” en la medida que los sindicatos no se planteaban como objetivo conseguir mejores condiciones económicas a través de la negociación colectiva mediante pluses de toxicidad o nocturnidad, sino que la lucha sindical se centraba en reivindicar la eliminación de los riesgos laborales. El segundo “la salud no se delega” que inspiró la actual Directiva Marco, puesto que se centra en la subjetividad de la salud laboral. Así pues, la lucha del movimiento sindical italiano reclamaba la participación obrera en la

137 Raúl Payá Castiblanque toma de decisiones en salud laboral y que no se vinculara únicamente a decisiones tecnocráticas de especialistas en prevención de riesgos (Vogel, 2016b). Dicha tradición histórica derivó en que los sindicatos italianos crearan, entre otras, la figura de los/as delegados/as de prevención territoriales por sector y localización geográfica, los/as llamados/as rappresentante dei lavoratori per la sicurezza territoriale o di comparto (“representantes/as de los/as trabajadores/as territoriales o sectoriales para la seguridad”), configurando una red de representantes especializados/as de carácter supraempresarial que ha permitido la penetración sindical en las empresas más pequeñas sin representación propia (Fulton, 2018), lo que explica su elevada cobertura representativa que llega, incluso, al 81 % en las empresas más pequeñas (ver Gráfica V). Así pues, observado el éxito del modelo italiano, la estrategia sindical del resto de países del sur podría pasar por consolidar sistemas de representación territorial para aumentar la cobertura en un tejido empresarial fragmentado. En este sentido, el artículo 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, sin embargo, pocos convenios recogen dichas cláusulas. La experiencia más desarrollada en España son los Acuerdos Interconfedereales para la creación y regulación de los delegados territoriales de prevención en el Principado de Asturias que llevan aplicándose desde el año 2005 con resultados positivos (González-Lada, 2006).

2.2.3. EROSIÓN Y LÍMITES DEL PODER INSTITUCIONAL EN SALUD LABORAL Las políticas neoliberales también han erosionado los recursos de poder institucional en los que históricamente se ha sostenido la fortaleza sindical del sistema latino o mediterráneo de relaciones laborales. Las reformas laborales de 2012 fueron utilizadas para debilitar el poder institucional de los sindicatos portugueses y españoles. Tal como señalan Alós et al. (2017), en España, la erosión de la negociación colectiva se articuló en tres frentes: a) descentralización de ámbitos priorizando el convenio de empresa al sectorial; b) facilitación a las empresas del descuelgue o inaplicación de los convenios sectoriales y c) eliminación de la ultraactividad, es decir, del carácter vinculante de los convenios colectivos tras expirar su período de vigencia y en tanto se renovaba su contenido. Leite et al. (2014) y Lima (2016) describen una situación similar en Portugal, sin embargo, la diferencia más importante, radica en que la normativa portuguesa ha limitado la extensión erga omnes de los convenios colectivos, lo que podría explicar (ver Tabla VIII) que a partir de 2012 empiece a reducirse notablemente la tasa de cobertura de los convenios publicados anualmente (del 48,4 % en 2012 al 19,3 % en 2015). No obstante, la cobertura total en 2015 fue del 80,1 %. A pesar de ello esta estadística general puede

138 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España ser engañosa, en la medida que los acuerdos anteriores a la reforma laboral todavía están vigentes. Mientras tanto, España al preservar la extensión de los convenios y sus cualidades durkheimianas, mantendrían el poder institucional en una tasa 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

Tasa de Tasa de Tasa de Tasa de cobertura cobertura cobertura Convenios cobertura de Convenios Año de de de publicados convenios publicados convenios convenios convenios publicados en vigor publicados en vigor

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

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

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 Relações Laborais (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.

Ahora bien, el hecho de mantener cierta tasa de cobertura puede encubrir las dificultadas de negociar aspectos cualitativos. De hecho, los estudios realizados muestran cómo condiciones de trabajo esenciales para la salud laboral (horario de trabajo, ritmos de producción, distribución regular de horarios etc.) habrían experimentado una fuerte erosión (Leite et al., 2014); Lima, 2016). A ello habría que sumar el retroceso en las estadísticas de las cláusulas cualitativas referidas a la salud y seguridad en el trabajo. En este sentido, tal y como se muestra en la Gráfica VI todos los

139 Raúl Payá Castiblanque aspectos relativos a la seguridad y salud laboral en España habrían sufrido una significativa reducción.

GRAFICA 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.

Finalmente, las políticas de austeridad también habrían debilitado la capacidad de intervención de la Inspección de Trabajo, encargada de vigilar y controlar el cumplimento normativo en materia de salud laboral. Dicha institución ha experimentado un fuerte descenso en el número de inspectores/as en los países del sur de Europa, como acreditan los respectivos informes anuales de las Inspecciones de Trabajo6 (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 ello habría que sumar que a diferencia del resto de países europeos que disponen una inspección especialista en salud laboral, en los del sur la inspección es de carácter generalista, acumulando una elevada carga de trabajo por tener que controlar el cumplimiento de toda la normativa, tanto la relativa a las relaciones de empleo y seguridad social como la correspondiente a

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.

140 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España la salud laboral (Castejón y Crespán, 2007). En definitiva, se trata de políticas deliberadas para socavar el poder de la Inspección de Trabajo y a su vez, de reducir las posibilidades de presión sindical para fortalecer las políticas de flexibilización empresarial.

CONCLUSIONES La investigación, cuyas principales conclusiones hemos presentado, tenía por objeto analizar el impacto de las políticas de austeridad económica y desregulación impuestas por la Troika sobre la salud laboral de los países del sur de Europa. Por un lado, se han identificado importantes desigualdades sociales entre el capital y trabajo, en la medida que los/las trabajadores/as por cuenta ajena en Portugal presentan cinco veces más probabilidades de sufrir accidentes de trabajo que los/las empresarios/as, como resultado de las condiciones de trabajo precarias a las que se encuentra sometida la población asalariada. Dicha precariedad afecta, asimismo, de forma desigual, siendo los/las trabajadores/as de sectores precarios de la construcción e industria y los/las de las pequeñas empresas los/las que presentan mayores índices de accidentabilidad laboral tanto en España como en Portugal. En segundo lugar, las personas más jóvenes son las que refieren mayor número de accidentes, debido a sus elevadas tasas de precariedad contractual ya que, como se ha analizado, la contratación temporal y la reducida antigüedad devienen como factores determinantes de la siniestralidad laboral. Por otro lado, tanto el estudio de los movimientos sindicales sobre la lucha contra la céruse y el fósforo blanco como el análisis de investigaciones empíricas, han acreditado el impacto positivo de la representación sindical especializada (delegados/as de prevención y comités de salud laboral) sobre la mejora de los estándares de salud laboral y la reducción de la siniestralidad. Sin embargo, las políticas neoliberales, también habrían debilitado los recursos de poder sindical (poder asociativo– reducción de la tasa de representación; poder institucional– erosión de la cobertura de la negociación colectiva en salud laboral), por lo que el efecto combinado de la degradación del mercado de trabajo junto al deterioro de las instituciones de representación sindical explicaría las elevadas tasas de accidentabilidad en los países del sur de Europa – a excepción del caso italiano, cuyo modelo de delegados territoriales de prevención operaría como alternativa estratégica.

RAÚL PAYÁ CASTIBLANQUE Instituto Universitario de Estudios de la Mujer, Universitat de València Avda. Blasco Ibáñez, 13, 46010 València, España Contacto: [email protected]

141 Raúl Payá Castiblanque Recibido: 02.01.2019 Aceptación comunicada: 29.05.2019

REFERENCIAS BIBLIOGRÁFICAS Alós, Ramón; Beneyto, Pere J.; Jódar, Pere (2017), “Reforma laboral y desregulación del mercado de trabajo”, Anuario IET de Trabajo y Relaciones Laborales, 4, 73-86. DOI: 10.5565/rev/aiet.55 Alós, Ramón; Jódar, Pere; Beneyto, Pere J.; Vidal, Sergi (2013), “La dinámica afiliativa sindical y las trayectorias de sus miembros”, Política y Sociedad, 50(3), 1065-1096. DOI: 10.5209/rev_POSO.2013.v50.n3.41602 Arcas, M. Marta; Novoa, Ana M.; Artazcoz, Lucia (2013), “Gender Inequalities in the Association between Demands of Family and Domestic Life and Health in Spanish Workers”, European Journal of Public Health, 23(5), 883-888. DOI: 10.1093/eurpub/cks095 Artazcoz, Lucia; Cortès, Imma; Borrell, Carme; Escribà Agüir, Vicenta; Casant, Lorena (2011) “Social Inequalities in the Association between Partner/Marital Status and Health among Workers in Spain”, Social Science and Medicine, 72(4), 600-607. DOI: 10.1016/j.socscimed.2010.11.035 Arocena Garro, Pedro; Núñez Aldaz, Imanol (2005), “El comportamiento cíclico de la siniestralidad laboral en España (1986-2004)”. Comunicación presentada en el VIII Encuentro de Economía Aplicada, 16-18 de junio, Departamento de Economía Aplicada, Universidad De Murcia, Murcia, España. Askenazy, Philippe (2005), “Sur les sources de l’intensification”, Revue économique, 56(2), 217- 236. DOI: 10.3917/reco.562.0217 Benavides, Fernando; Benach, Joan; Muntaner, Carles; Delclós, Jordi; Catot, Nuria; Amable, Marcelo (2006), “Associations between Temporary Employment and Occupational Injury: What Are the Mechanisms?”, Occupational and Environmental Medicine, 63(6), 416-421. DOI: 10.1136/oem.2005.022301 Benavides, Fernando; Delclós, Jordi; Serra, Consol (2018), “Estado de bienestar y salud pública: el papel de la salud laboral”, Gaceta Sanitaria, 32(4), 377-380. DOI: 10.1016/j.gaceta.2017.07.007 Beneyto, Pere Josep (2017), “Crisis y renovación del sindicalismo”, Arxius de Ciències Socials, 36/37, 15-34. Boix, Pere; Orts, Enrique; López, María José; Rodrigo, Fernando (1997), “Trabajo temporal y siniestralidad laboral en España en el período 1988-1995”, Cuadernos de Relaciones Laborales, 11, 275-319. Castejón, Emili; Crespán, Xavier (2007), “Accidentes de trabajo: [casi] todos los porqués”, Cuadernos de Relaciones Laborales, 25(1),13-57.

142 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España

Costa, Hermes Augusto (2012), “From Europe as a Model to Europe as Austerity: The Impact of the Crisis on Portuguese Trade Unions”, Transfer, 18(4), 397-410. DOI: 10.1177/1024258912458866 Coutrot, Thomas (2009), “Le rôle des comités d’hygiène, de sécurité et des conditions de travail en France: une analyse empirique”, Travail et Emploi, 117, 25-38. DOI: 10.4000/travailemploi.4108 Crouch, Colin (2017), “Membership Density and Trade Union Power”, Transfer, 23(1), 47-61. DOI: 10.1177/1024258916673533 Eaton, Adrienne; Nocerino, Thomas (2000), “The Effectiveness of Health and Safety Committees: Results of a Survey of Public-Sector Workplaces”, Industrial Relations, 39(2), 265-290. DOI: 10.1111/0019-8676.00166 Eurostat (s. d.), “Accidents at Work (ESAW, 2008 onwards) (hsw_acc_work)”. Consultado el 12.11.2018, en https://ec.europa.eu/eurostat/cache/metadata/fr/hsw_acc_work_esms.htm. Eurofound (2015), “Sixth European Working Conditions Survey: 2015”. Consultado el 27.11.2018, en https://www.eurofound.europa.eu/surveys/european-working-conditions-surveys/sixth- european-working-conditions-survey-2015. EU-OSHA (2009), “European Survey of Enterprises on New and Emerging Risks (ESENER)”. Consultado el 27.11.2018, en https://osha.europa.eu/es/surveys-and-statistics- osh/esener/2009es. EU-OSHA (2010), “European Survey of Enterprises on New and Emerging Risks: Managing Safety and Health at Work”. Luxembourg: Publications Office of the European Union. Consultado el 20.11.2018, en https://osha.europa.eu/en/node/6745/file_view. EU-OSHA (2014), “Second European Survey of Enterprises on New and Emerging Risks (ESENER-2)”. Consultado el 27.11.2018, en https://osha.europa.eu/es/surveys-and- statistics-osh/esener/2014es. Fonseca, Dora; Estanque, Elísio (2018), “Sindicalismo e lutas sociais em tempos de crise”, e-cadernos CES, 29, 213-236. DOI: 10.4000/eces.3483 Fulton, L. (2018), “Health and Safety Representation in Europe”, Labour Research Department and ETUI. Consultado el 28.11.2018, en http://www.worker-participation.eu/National-Industrial- Relations/Countries/Italy/Health-and-Safety. Gónzalez-Lada, Heidi María (2006), “Los delegados y delegadas territoriales de prevención ya son una realidad en Asturias”, porExperienca – Revista de Salud Laboral de ISTAS-CCOO , 34. Consultado el 28.11.2018, en https://www.porexperiencia.com/articulo.asp?num=34&pag=20&titulo=Los-delegados-y- delegadas-territoriales-de-prevencion-ya-son-una-realidad-en-Asturias. Gumbrell-McCormick, Rebecca; Hyman, Richard (2013), Trade Unions in Western Europe: Hard Times, Hard Choices. Oxford: Oxford University Press. Instituto per il Lavoro (2006), “The Role of the Safety Representative in Italy”. Consultado el 27.11.2018, en https://www.etui.org/content/download/2632/29453/file/IPL.pdf&sa=U&ei=m-

143 Raúl Payá Castiblanque

jRUOKuOPT64QTY6ICoAg&ved=0CBYQFjAA&usg=AFQjCNHJyM4D3dRoroCN59aIwP2ny xK1Ug.pdf. Leite, Jorge; Costa, Hermes Augusto; Silva, Manuel Carvalho da; Almeida, João Ramos de (2014), “Austeridade, reformas laborais e desvalorização do trabalho”, in José Reis (coord.), A economia política do retrocesso: crise, causas e objetivos. Coimbra: CES/Almedina, 127- 188. Lehndorff, Steffen (2015), “Acting in Different Worlds. Challenges to Transnational Trade Union Cooperation in the Eurozone Crisis”, Transfer, 21(2), 157-170. DOI: 10.1177/1024258915573184 Lehndorff, Steffen; Dribbusch, Heiner; Schulten, Thorsten (2017), European Trade Unions in a Time of Crises. Brussels: European Trade Union Institute. Lima, Maria da Paz Campos (2016), “O desmantelamento do regime de negociação coletiva em Portugal, os desafios e as alternativas”, Cadernos do Observatório, 8. Consultado el 29.11.2018, en https://www.ces.uc.pt/observatorios/crisalt/documentos/cadernos/CadernoObserv_VIII_N8_ VERSAO_REFORMULADA.pdf. Lima, Teresa Maneca (2002), “A (in)sustentável segurança no mundo das incertezas: políticas de regulação do risco”. Tese de licenciatura em Sociologia, Faculdade de Economia da Universidade de Coimbra, Coimbra, Portugal. Lima, Teresa Maneca (2004), “Trabalho e risco no sector da construção civil em Portugal: desafios a uma cultura de prevenção”, Oficina do CES, 211. Consultado el 16.10.2018, en https://ces.uc.pt/pt/publicacoes/outras-publicacoes-e-colecoes/oficina-do- ces/numeros/oficina-211. Lima, Teresa Maneca (2015), “O que a lei não vê e o trabalhador sente: o modelo de reparação dos acidentes de trabalho em Portugal”. Tese de Doutoramento em “Direito, Justiça e Cidadania no século XXI”, Faculdade de Economia da Universidade de Coimbra, Coimbra, Portugal. Monjardino, Teresa; Lucas, Raquel; Benavides, Fernando G. (2017), “Trabalho e Saúde em Portugal 2016, un primer informe sobre la salud laboral en Portugal”, Archivos de Prevención de riesgos laborales, 20(1), 6-8. DOI: 10.12961/aprl.2017.20.01.1 Narocki, Claudia (1997), “La prevención de riesgos laborales en las pequeñas y medianas empresas españolas”, Cuadernos de Relaciones Laborales, 10, 157-181. Nichols, Theo; Walters, David; Tasiran, Ali C. (2007), “Trade Unions, Institutional Mediation and Industrial Safety: Evidence from the UK”, Journal of Industrial Relations, 49(2), 211-225. DOI: 10.1177/0022185607074919 Ollé-Espluga, Laia; Vergara-Duarte, Montse; Belvis, Francesc; Menéndez-Fuster, María; Jódar, Pere; Benach, Joan (2015), “What is the Impact on Occupational Health and Safety When Workers Know They Have Safety Representatives?”, Safety Science, 74, 55-58. DOI: 10.1016/j.ssci.2014.11.022

144 Contexto económico y determinantes sociales de la accidentabilidad laboral en Portugal y España

Payá, Raúl (2014), “La participación de los trabajadores en seguridad y salud laboral. Una perspectiva europea”, Estudios, 88. Consultado el 27.11.2018, en http://www.relats.org/documentos/SST.Europa.PayaCastiblanque.pdf. Payá, Raúl; Beneyto, Pere Josep (2018a), “Participación sindical y salud laboral: una relación positiva”, Barataria – Revista Castellano-Manchega de Ciencias Sociales, 24, 61-81. DOI: 10.20932/barataria.v0i24.402 Payá, Raúl; Beneyto, Pere J. (2018b), “Intervención sindical y salud laboral en la Unión Europea: dimensiones, cobertura e impacto”, methaodos.revista de ciencias sociales, 6(2), 210-226. DOI: 10.17502/m.rcs.v6i2.238 Rainhorn, Judith (2010), “Le mouvement ouvrier contre la peinture au plomb. Stratégie syndicale, expérience locale et transgression du discours dominant au début du XXe siècle”, Politix 3(91), 7-26. DOI: 10.3917/pox.091.0007 Reilly, Barry; Paci, Pierella; Holl, Peter (1995), “Unions, Safety Committees and Workplace Injuries”, British Journal of Industrial Relations, 33(2), 275-288. DOI: 10.1111/j.1467- 8543.1995.tb00435.x Rigby, Mike; García-Calavia, Miguel Ángel (2018), “Institutional Resources as a Source of Trade Union Power in Southern Europe”, European Journal of Industrial Relations, 24(2), 129-143. DOI: 10.1177/0959680117708369 Robinson, Andrew M.; Smallman, Clive (2013), “Workplace Injury and Voice: A Comparison of Management and Union Perceptions”, Work, Employment and Society, 27(4), 674-693. DOI: 10.1177/0950017012460307 Rueda, Silvia (2004), “Siniestralidad laboral y fortaleza sindical en la OCDE”, Archivos de Prevención de Riesgos Laborales, 7(4), 146-152. Terrés, Fernando; Rodríguez, Pedro; Álvarez, Enrique; Castejón; Emilio (2004), “Economic Fluctuations Affecting Occupational Safety. The Spanish Case”, Occupational Ergonomics, 4(4), 211-228. Sánchez, Carmen; Conde, Pilar (2008), “La protección social y los riesgos psicosociales”, Anales de Derecho, 26, 257-297. Santos, Boaventura de Sousa; Gomes, Conceição; Ribeiro, Tiago; Soares, Carla (2010), “A indemnização da vida e do corpo na lei e nas decisões judiciais”. Coimbra: Centro de Estudos Sociais. Stuckler, David; King, Lawrence; McKee, Martin (2009), “Mass Privatisation and the Post- Communist Mortality Crisis: A Cross-National Analysis”, The Lancet, 373(9661), 399-407. DOI: 10.1016/S0140-6736(09)60005-2 Vogel, Laurent (2016a), “El decisivo papel de la representación de los trabajadores para la salud en el trabajo”, RELATS – Red Eurolatinoamericana de Análisis sobre Trabajo y Sindicalismo. Consultado el 27.11.2018, en http://www.relats.org/documentos/SST.Europa.Vogel2016.pdf. Vogel, Laurent (2016b), “La actualidad del modelo obrero italiano para la lucha a favor de la salud en el trabajo”, Laboreal, 12(2), 10-17. DOI: 10.15667/LABOREALXII0216LV

145 Raúl Payá Castiblanque

Walters, David (2004), “Worker Representation and Health and Safety in Small Enterprises in Europe”, Industrial Relations Journal, 35(2), 169-186. DOI: 10.1111/j.1468- 2338.2004.00307.x Walters, David; Nichols, Theo (2007), Worker Representation and Workplace Health and Safety. Basingstoke: Palgrave Macmillan.

146 e-cadernos CES, 31, 2019: 147-169

STEFANO NERI

THE ITALIAN NATIONAL HEALTH SERVICE AFTER THE ECONOMIC CRISIS: FROM

DECENTRALIZATION TO DIFFERENTIATED FEDERALISM

Abstract: This essay analyses the evolution of the National Health Service (NHS) in Italy after the beginning of the financial crisis of 2008, focusing on some trajectories of change underway in the NHS governance. It starts with a reconstruction of the economic and financial framework of the NHS in the last 10 years, briefly describing the austerity policies implemented in the health sector. It then outlines the NHS institutional framework as it emerged from 1990s reforms, which is based on intergovernmental relations and joint policy-making between the State and the Regions. In the third part, it shows how the response to the economic crisis has had a significant effect on these relations, triggering a transformation in the NHS governance. This change, which is far from being concluded, could seriously undermine the universalistic nature of the Italian NHS and its ability to pursue the values of equity and solidarity, especially at a territorial level. Keywords: decentralization, economic crisis, governance, health care, national health service.

O SERVIÇO NACIONAL DE SAÚDE ITALIANO APÓS A CRISE ECONÓMICA: DA

DESCENTRALIZAÇÃO AO FEDERALISMO DIFERENCIADO

Resumo: Este artigo analisa a evolução do Serviço Nacional de Saúde (SNS) na Itália após o início da crise económica de 2008, focando-se em algumas das trajetórias de mudança ocorridas sob a governança do SNS. Aborda, inicialmente, a reconstrução da estrutura económica e financeira do SNS nos últimos 10 anos, descrevendo brevemente as políticas de austeridade implementadas no setor da saúde. De seguida, delineia a estrutura institucional do SNS a partir das reformas dos anos 1990, que se baseiam nas relações intergovernamentais e na formulação conjunta de políticas entre o Estado e as regiões. Na terceira parte, mostra como a resposta à crise económica teve um efeito significativo nestas relações, desencadeando uma transformação na governança do SNS. Esta mudança, longe de estar concluída, pode comprometer seriamente a natureza universalista do SNS italiano e a sua capacidade para seguir os valores de equidade e solidariedade, especialmente a nível territorial. Palavras-chave: crise económica, cuidados de saúde, descentralização, governança, Serviço Nacional de Saúde.

147 Stefano Neri

1. THE ECONOMIC CRISIS AND THE NATIONAL HEALTH SERVICE IN ITALY Italy was one of the European Union (EU) countries hardest hit by the recession that began 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, when the Italian Gross Domestic Product (GDP) declined by 1.1% and 5.5% respectively from the previous year. There was an overall weak recovery in the following two years, while in 2012 the crisis heightened and the GDP dropped by 2.8%, followed by a further decline of 1.7% in 2013. In 2014-2015 the GDP growth trend was very slack and became a little more sustained in recent years (1.1% in 2016 and 1.6% in 2017), although, in real terms, 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 2019 seems to indicate a substantial weakening in the recovery. In all these years, the GDP 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 Euro area.

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).

The recession had a very strong impact on the relationship between the GDP and public debt. Since 1991-1992, this ratio had always been at more than 100%, one of the highest in Europe – except for 2007 (99.8%). However, since the start of the economic crisis it has progressively increased reaching close to 130% of the GDP in 2013 and surpassing even 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).

148 The Italian NHS after the Economic Crisis: From Decentralization to Differentiated Federalism Beyond the data, the financial crisis became particularly serious in 2011-2012, since it was accompanied by the widespread perception – by the international markets and European institutions – that the Italian government was no longer able to cope with the situation and bring the debt under control (Jones, 2012). As is known, this resulted in a sovereign debt crisis, expressed by the increased interest rates on Treasury bonds and the spread relating to German government bonds. Politically, the crisis resulted in the fall of the Berlusconi Government, at the end of 2011, which was replaced by a “technical” executive, headed by the economist Mario Monti. In the context of a protracted financial crisis and lack of confidence of the international environment, as well as prolonged stagnation and recession, strict measures had to be taken to control the budget deficit, reduce expenses and increase public revenues. In some areas, these measures were accompanied by structural reforms, as in the case of pensions and, later, of labour market, while this was not the case in health care. Austerity policies, the details of which will be further discussed, had crucial goals for government expenses, including staffing costs. The restrictive measures taken since 2008 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 been to recalibrate expenditure levels already lower than the average values recorded in comparable continental and Northern European countries, and in line with the other 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 less than 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 Health Statistics).1 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 European countries (Table 3). Starting from a pre-crisis value of 6.3% (2007), the Italian government expenditure-GDP ratio did not grow even by half a percent in the following decade (6.6% in 2016 and in 2017 estimation), despite the inevitable increase in demand for services – with a steadily aging population – and despite the increase in the costs of implementing new technologies in diagnostic and therapeutic services. Similarly, public expenditure per capita on health services increased of less than 19% from 2007 to 2016, a share

1 Accessed on 30.12.2018, at http://www.oecd.org/els/health-systems/health-data.htm.

149 Stefano Neri much lower than in the main continental and Northern Europe countries reported in Table 3. Italian trends in public expenditure on health are more similar to those of other Mediterranean European countries such as Portugal and Spain, although, from 2007 to 2016, 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

Growth of Share of GDP (%) Per Capita (US$PPP) 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).

At the same time the share of private health expenditure over total expenditure on health, while diminishing in France, Germany and Sweden, increased in the UK, Italy and in other Southern European countries (Table 4). In Italy, from 2007 to 2016 it shifted from 22.5% to 25.5% of total health expenditure, therefore coming to represent more than a quarter of total health expenditure (with OECD provisional data and estimations showing a further increase for 2017). This brought the level of private health expenditure closer to that of Spain.

150 The Italian NHS after the Economic Crisis: From Decentralization to Differentiated Federalism

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

Difference 2007 2016 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).

In the Italian case the out-of-pocket component is very high, being more than 90% of the total private health expenditure. However, the growth of private health expenditure during the crisis was due to the insurance component, even more than the out-of-pocket factor. In this regard, one of the most recent transformations that has taken place in Italy in relation to private health expenditure is the spread of supplementary, or integrative, occupational health funds for workers and their families, introduced or reintroduced from national negotiations or unilateral initiatives made by companies. Almost non-existent at the end of the 1990s, supplementary occupational health funds have rapidly increased in the last decade, to cover 35% of the total number of employed persons. This threshold is particularly high when compared with the more marginal role that such insurance programs play in health care in other European countries (Natali and Pavolini, 2014). The increasing popularity of occupational health funds is due primarily to the dynamics inherent in the industrial relations system during the crisis. However, it also reveals the state of health and coverage of the Italian National Health Health Service (NHS). By increasingly funding the provision of basic health services, such as diagnostics and specialized care that should be covered by the NHS, it is clear how these funds are often operating in substitution 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 big firms, mainly located in the north of Italy, the spread of occupational funds brings serious risk to deepen the traditional differences existing in service access and quality between the north and the south of the country (Arlotti et al., 2018).

151 Stefano Neri

2. AUSTERITY POLICIES IN THE NHS Within a general approach aimed at reducing public expenditure and the weight of the public sector in the economy, the austerity policies directed to the NHS had as main objective the containment and control of public health expenditure, if not its reduction. This was done in a context where health expenditure (public or private) is expected to grow in the medium and long term, for the reasons we have already briefly mentioned. In the Italian highly regionalized NHS, control of health expenditure by the central government was pursued primarily through extremely limited increases and, in some cases, reductions in the level of funding attributed by the central government to the Regions to finance the “Essential Levels of Health Care” (Livelli Essenziali di Assistenza, or LEAs), that is the set of services to be provided nationwide. Absolute values and percentages of annual funding increases confirmed a stagnation in the central government appropriations from 2010 onwards, with generally very reduced surges but also drops compared to the previous years, in 2013 and in 2015 (Table 5).

TABLE 5 – Financing of the Central Funding for LEAs

Financing Percentage of change (in millions of €) 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).

One could object that in the first part of the 2000s the yearly growths were more substantial. However, we should remember that the restrictions in the central funds allocated in the last seven-eight years would, comparatively speaking, have had an impact on very low expenditure levels (Giarelli, 2017).

152 The Italian NHS after the Economic Crisis: From Decentralization to Differentiated Federalism The level of annual funding of LEAs is calculated in the budget laws, called “stability laws”. 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 the State-Region Agreements or the Pacts for Health. However, the Parliament and the central government can modify the concerted funding levels, as has always occurred in fact, after the beginning of the crisis with reductions in the originally agreed funds. Besides the containment of general central funding, austerity policies addressed the control of specific sources of expenditure arising from the acquisition of production inputs. The main cost containment programmes started in 2009-2010 and intensified in the following years, culminating in the so-called “Spending Review” on public administration, 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 in 2017-2018. Targets like the following were pursued:3 1) “rationalization” policies on pharmaceutical expenditure, which included spending caps on the global expenditure, passed from 16.4% of the total NHS financing in 2008 to 14.85% in 2017, incentives for generic drugs, reductions in quotas attributable to pharmaceutical companies, wholesalers and pharmacists on the sale price of drugs, as well as a general review of the remuneration system of the drug distribution chain; 2) reduction in hospitalization rates, setting, in 2012, the target of 160 total admissions for 1,000 inhabitants (of which 25% for the outpatients), against a rate which in 2010 was calculated at 175-180 admissions for 1,000 inhabitants. In the same year national legislation introduced also a mandatory statute, by Regions, to reduce the number of hospital beds from 4 to 3.7 per 1,000 inhabitants, including 0.7 beds for rehabilitation and long-term nursing care. The reduction was borne by the public providers for a quota of not less than 50%; 3) 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; 4) general restrictions of the expenditure on purchases of goods and services. In 2012-2013 there was a 10% reduction of all existing contracts for the

2 Law Decree No. 95, 6 July 2012, converted into Law No. 135, 7 August 2012, “Conversione in legge, con modificazioni, del decreto-legge 6 luglio 2012, n. 95, recante disposizioni urgenti per la revisione 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 documents published on the website of the Chamber of Deputies (la Camera dei Deputati, one of the two branches 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.

153 Stefano Neri procurement and supply of goods and services stipulated by the NHS health authorities. These drastic measures were progressively accompanied by instruments that monitored and controlled the conclusion and implementation of purchase contracts; 5) increasing revenues: by increasing the co-payments for citizens, with the introduction or rescheduling of copayments on first aid, specialized outpatient and pharmaceutical industries. In this field, the most discussed measure was the “superticket”, a sharing of the expense 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 the superticket, accepting it indiscriminately, and modifying it according to income or, in some cases, denying it. This last option is spreading in 2018-2019. These measures were added to those aimed at controlling staff expenditure in all public services (Bordogna and Neri, 2014), which are of particular significance due to the importance of human resources in the health sector. There were two main types of measures addressed to NHS staff: measures aimed at gradually reducing the number of employees and others at containing wages and salaries. In the first case, at the end of 2006, and thus before the start of the crisis, a cap for personnel expenditure for 2007, 2008 and 2009, equal to the “corresponding amount of the year 2004 reduced by 1.4%” (including costs for temporary employees and autonomous workers) was introduced in the NHS. This measure was first confirmed for the three-year period 2010-2012, establishing that the cap was to be considered as net of expenses arising from contract renewals occurring after 2004. Then the same constraint was extended to 2013-2014 and in the following years, having been in force until 2019. To meet the cap, Regions could adopt several measures of health facilities and service re-organization. However, a predictable result of the cap and other similar measures was a slow down and substantial stop in the staff hiring and turnover within the NHS health care organizations. 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 took as reference the initial year of 2009, when the staffing of the NHS amounted to 693,716 units (Ministero dell’Economia e delle Finanze, 2018). The decrease in the number of staff during the crisis was stronger in other areas of public administration, such as the central and local government, but it was nevertheless a significant drop, considering that the Italian health care service is understaffed compared to many European countries (Vicarelli, 2015).

154 The Italian NHS after the Economic Crisis: From Decentralization to Differentiated Federalism Staff hiring was re-opened in 2017-2018, especially after that the new national NHS collective agreeement signed in 2018 opened the possibility to hold extraordinary public competitions for the new recruitment of doctors, nurses and technical health personnel. These measures were confirmed by the stability law for 2019, which suspended 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 care staff within the NHS, which will become more serious in the next years considering the predictable wave of retirements connected to an aging labour force, especially among doctors (Vicarelli and Pavolini, 2015). Furthermore, a second type of measures was introduced in 2008 and reinforced in 2010-2011, which concerned the containment of wages for civil servants (Law Decrees No. 78/20104 and No. 98/20115). These measures also affected employees in the NHS, as well as independent professionals working for the NHS, starting from the general practitioners and paediatricians. After very moderate wage increases in 2008-2009, equal to half of the increase established 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 million contractualized public employees, including NHS staff. The suspension was then extended until 2015, when a sentence of the Constitutional Court forced the government to re-start the collective bargaining process in the public sector. A new national NHS collective agreement for the period 2016-2018 was signed in May 2018, with modeste pay increases. Collective negotiations at decentralised level in the public sector, including the NHS, were not frozen, but were put under very strict financial constraints. The overall effect of these provisions was to freeze the salaries of NHS employees for eight years, substantially to the levels of 2010. In addition to these measures, there were also specific measures addressing the Regions in conditions of high deficit in the health sector and therefore subjected to a recovery plan, which will be dealt within the second part of the article.

4 Law Decree No. 78, 31 May 2010, converted into Law No. 122, 31 July 2010, “Conversione in legge, con modificazioni, del decreto-legge 31 maggio 2010, n. 78, recante misure urgenti in materia 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 del testo del decreto-legge 6 luglio 2011, n. 98 (in Gazzetta Ufficiale – Serie generale – n. 155 del 6 luglio 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 stabilizzazione finanziaria’” (available at https://www.gazzettaufficiale.it/eli/id/2011/07/25/11A10000/sg).

155 Stefano Neri

3. THE CONSEQUENCES OF THE FINANCIAL CRISIS ON INTER-GOVERNMENTAL RELATIONS The economic crisis and the austerity policies have favoured a partial reversal of the trend in the evolution of relations between different levels of government compared to previous decades. The increasing regionalization of the system, started at least since the 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 with a significant impact on spending, on the other hand, by a substantial (more than formal) differentiation in the powers and responsibilities among the Regions, depending on whether or not they are subject to a plan for the reduction of health deficits. To understand these dynamics, it would be useful to reconstruct the reasons and the characteristics assumed by the regionalization of the NHS starting from the 1992-1993 reforms (for an historical and updated reconstruction).

3.1. DECENTRALIZATION IN THE NHS: THE RISE OF REGIONALISM (1992-2008) Unlike the oldest national health services, such as those of England or Sweden, the Italian NHS has always had a decentralized structure, in line with the Italian Constitution. In a first phase (1978-1992) the powers and responsibilities were divided among 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 the NHS was introduced, together with its managerialization (France and Taroni, 2005; Giarelli, 2017). Although they drew origin from the debate launched in the mid-1980s on the crisis of the NHS, the reforms were approved in the midst of the political and judicial earthquake after the general elections of 1992 and the impressive wave of corruption scandals known as Tangentopoli (“Bribesville”), which brought to the collapse of the old political system of the First Republic (1946-1992). To this, we must add also the context of the economic and financial crisis, which led to the devaluation of the national currency (the Lira) in September of that year. It was therefore necessary to intervene on an expenditure area as important as health care with not only urgent austerity measures (cuts, expenditure caps, copayments and new taxes), but also with structural measures. Apart from the contingent emergency, the reforms were considered necessary to allow the entry of Italy into the euro currency, in compliance with the convergence criteria laid down in the Maastricht Treaty signed in February 1992. In this context, regionalization is the result of a convergence of objectives between the policy 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 powers and responsibilities when, presumably, it would have been necessary to undertake a policy of austerity and retrenchment in health care for several years.

156 The Italian NHS after the Economic Crisis: From Decentralization to Differentiated Federalism Regional decentralization was thus seen as a way to share or remove highly unpopular decisions. On the other hand, regionalization was considered an opportunity for Regional administrators to make visible and legitimize their level of government which, unlike the municipalities, had only been established for some decades and was perceived by the citizens as distant and not very visible. In particular, the implementation of 1992/1993 reforms allowed Regional Governments to initiate policies that could instate principles and core values (trust in the public or in private sector, the State or the market) that were distinct and clearly recognizable by the general public. In particular, the adoption of managed competition (Enthoven, 1985), which evolved into managed cooperation (Light, 1997), gave Regions the opportunity to implement quite divergent policies, in terms of organisation and regulation of the single Regional Health Services. 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 plan service organisation and distribution on the territory, being able to respond adequately to 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. In fact, the regionalization of the NHS undertaken from 1992-1993 was at the same time a process of decentralization from the State to the Regions and of centralization by the local government to the regional level. Moreover, there was the conviction that greater autonomy and empowerment of the Regions could push those of the South to promote policies to reduce existing disparities in service access and quality, more effectively than what the central State had been able to do up to that point. The main powers in planning, organization and management of health services were then attributed to the 20 Regions and the Autonomous Provinces of Trento and Bolzano. New NHS providers, the local health authorities (Aziende Sanitarie Locali) and the autonomous hospitals (Aziende Ospedaliere) were instituted as Regional entities and were organized according to the New Public Management principles. Regionalisation was then strengthened by the Constitutional reform introduced in 2001 and confirmed by the failures of subsequent attempts of Constitutional reforms in 2006 and 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 the economic resources necessary for LEA provision. NHS central funding for LEAs is defined through negotiations between the central government and Regions. The Regions have great freedom in organization and management of their Regional Health Services. Starting from the second half of the 1990s, different Regional health care models emerged, characterized by regulatory structures marked by hierarchical

157 Stefano Neri integration, cooperation or competition between purchasers and service providers (Mapelli, 2007; Neri, 2011). These institutional and organizational differences among Regional Health Services still exist, although some convergence processes emerged in the 2000s (Maino and Neri, 2011). NHS regionalization included a certain degree of fiscal autonomy, even if very restricted (see Bordignon et al., 2002), as well as the possibility of introducing co- payments for drugs and outpatient services at Regional level. In 2009, fiscal decentralization could have expanded considerably after the approval of Law No. 42;6 however, the implementation of this law was hampered by many difficulties, and the economic and financial crisis caused its postponement.

3.2. THE RE-ASSERTION OF THE ROLE OF THE STATE The division of powers that emerged from the decade 1992-2001 required a permanent mechanism of negotiation and, possibly, cooperation between the State and the Regions to define national health policy. In fact, after 2001, the State (the central government and the Parliament) could not approve structural reforms such as those of the 1990s without the consent and involvement of the Regions, which was essential for reform implementation. However, the central government retained a considerable control over financial resources, in particular those intended for the financing of the LEAs. Moreover, as the last ten years has clearly shown, the central government and the Parliament retained a significant capacity of affecting NHS management and organization at Regional and local level, by introducing national regulation which Regions are then called to implement. Since the late 1990s, the national health policy, like that of other policy sectors with high decentralization, has developed mainly through negotiated or joint forms of policy- making, which is based on a system of Conferences between the State, Regions and local government. Among those Conferences, the most relevant to health is the State- Regions Conference, established in 1988 and then reinforced in 1997 and 2003. In the State-Regions Conference, central government and Regions are represented at the highest political level. Central (that is, national) government is represented by the Prime Minister and the National Ministers, while each Region is represented by its Regional Governor and the Regional Ministers. In the case of health care, the National and Regional Ministers involved in the policymaking will be the National Minister of Health and the Regional Minister of Health (one Minister of Health for each of the 20 Regions). The majority of the most important health policy decisions are thus taken through

6 Law No. 42, 5 May 2009, “Delega al Governo in materia di federalismo fiscale, in attuazione dell’articolo 119 della Costituzione” (available at https://www.gazzettaufficiale.it/eli/gu/2009/05/06/103/sg/pdf).

158 The Italian NHS after the Economic Crisis: From Decentralization to Differentiated Federalism “Agreements” or “Pacts” deliberated by the State-Regions Conference and translated into law by the Parliament (Carpani, 2006; Fargion, 2006). The role of the State-Regions Conference was central to the process of making the Regions responsible for managing expenditure, which had become a crucial element in ensuring the convergence of Italy to the Maastricht parameters, then translated into the European Stability and Growth Pact. In a decentralized institutional framework such as that of the 2000s, the involvement of the Regions was essential and ensured by means of acts, such as many State-Regions agreements and pacts (usually called “Pacts for Health”), which have been signed within the State-Regions Conference between the central government, on one side, and the Regions, on the other, over the last 20 years. Although none of regulatory changes had modified the balance of the powers we have described, the economic and financial crisis weakened the role of the Regions in national policy making, in favour of greater importance of the role played by the central government, the Ministry of Economy and Finance (MEF) and, indirectly, by the European institutions. This was not a trend limited to health care, but in this area it was perhaps more significant as regional decentralization was extended and consolidated 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 health policy, in favour of a more one-sided process that took place within the central government, in cooperation with the EU and the European Central Bank. This shift that started before the crisis grew from 2008-2009 and became particularly evident after the explosion of the sovereign debt crisis of 2011-2012. The need to take urgent measures – able to signal to international markets and the EU the willingness and ability of the national government to bring the public debt under control – have prompted approval of austerity packages by the central goverbment, which in great part had not been agreed upon and basically not even discussed with the Regions, Parliament and organized interests. The minimization of room for discussion and negotiation was motivated by the lack of time and alternatives in the face of the commitments 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 by overwhelming external restrictions was a very effective strategy to avoid negotiation, using a combination of blame avoidance and credit claiming (Bonoli and Natali, 2012). These dynamics did not occur only in Italy but were common to all the European countries most affected by the financial crisis and sovereign debt, namely those of Southern 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 adopt

159 Stefano Neri structural 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 the International Monetary Fund (Greece, Portugal, Ireland). In this context, national governments and, within it, Prime Ministers and the Ministers of Economy and Finance have become guarantors and accountable at European and international institutions for the adoption of interventions or negotiations, according to each case, imposed by such institutions in exchange for direct or indirect financial support. Applying these measures quickly and with little margin for change than those already defined at European or international level, had somehow determined an exclusion of traditional negotiations with the parliaments, local government and organized interests. In the Italian case, these trends seemed particularly evident in some reforms like those of pensions in late 2011 and the adoption of austerity packages on public expenditure and 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 central government, Parliament, Regions and also organized interests (i.e. doctors) to the top-down relations between European institutions and the central government, within which the role of the Prime Ministers and the Ministers of Economy and Finance stand out (Marangoni and Tronconi, 2014; Frisina-Doëtter and Neri, 2018a; 2018b). The role of the Regions has significantly weakened in the definition of health policy and, consequently, also that of the State-Regions Conference, even if there were no changes in the legislative assignments. This was particularly evident in the process of determining the annual NHS central funding for LEAs. The definition of the allocations took place through a negotiation between the State and the Regions, which resulted in agreements, 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 the stability laws or other austerity packages, with decisions substantially taken by the central government and, in particular, by the MEF, and has involved very limited possibilities or even the absence of modification by the Regions. According to information gathered in some interviews carried by the author of this article with some managers and officers of the State-Regions Conference in 2016, the most striking example of this process took place in the case of definition of the NHS central funding for 2013. In this circumstance, the Regions protested loudly, but to no avail, against the downward revision of the NHS funding for 2013, which was significantly lower than that of 2012, both in percentage terms and in real terms (see Table 5). The weakening of the role of the Regions in national policy making is not only due to political and institutional dynamics set in motion by the financial crisis, but also, in part,

160 The Italian NHS after the Economic Crisis: From Decentralization to Differentiated Federalism 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 of the public, Regional politicians thus began to appear among the major representatives of a “caste”, i.e. the political class, unable to administer public affairs efficiently and dedicated almost exclusively to its own particular interests. For a “young” institution like the Regional one, introduced only in 1970, this phenomenon translated into a rather serious loss of legitimacy, to the point that, even in the national press, some commentators began to wonder what the Regions were for. Doubts about regionalization or, at least, the way it was began to spread also among experts, in the light of research that highlighted the persistence if not an increase in regional inequalities, after 20 years of regionalism (Pavolini and Vicarelli, 2012; Toth, 2014).

4. FROM TERRITORIAL TO INSTITUTIONAL DIFFERENCES? NORTH AND SOUTH BETWEEN

GREATER AUTONOMY AND CENTRAL PROTECTION In a comparative perspective, OECD data show that, according to many indicators, the Italian NHS performs quite well in terms of health equity, service access and quality, as well as of overall efficiency. Always in comparative terms, these performances by and large 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 inequities among 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 et al., 2017). However, as it is well known, data at national level hide the existence of relevant inequalities between North and South in the service access and quality, as well as in the efficiency of the Regional health care systems. Although these differences are historically rooted, since 1990s they have increased rather than decreased (Pavolini and Vicarelli, 2012; Toth, 2014, 2016; Sarti, 2017). Although over time the NHS exerted a significant effort to reduce territorial differences in expenditure for health services (Mapelli, 2012), this was not translated into a correspondent reduction of the differences existing in terms of service quality and efficiency between different areas of the country. Quite the opposite, the North-South gap was widened in the years of NHS regionalization, instead of filled (Toth, 2014). In this context, the economic crisis triggered relevant changes in the NHS governance and in the relationships between State and Regions. First, as described in the previous paragraph, the crisis had contributed to determine a partial but significant re-centralization of national health policy making. Moreover, it promoted the re-assertion

161 Stefano Neri of the role of the State in the governance of the Italian NHS, by highlighting the importance of some institutional mechanisms, which had been created before the crisis. Even in this case, the central government was called to re-affirm its role to tackle problems of financial nature. In fact, already in the mid-2000s, the inability of some Regions to keep their health service in a financial equilibrium had clearly emerged. Disputes between the State and the Regions on the responsibilities of health deficits had been frequent since the birth of the NHS. However, during the 2000s European commitments made regarding the containment of the public debt as well as NHS regionalization saw the opportunity of defining a mechanism, which allowed the central government to intervene to ensure control of health expenditure at regional level. This mechanism became essential in the years of financial crisis. On this purpose, the budget law for 20057 and, above all, the State-Regions Agreement of 23 March 20058 (with subsequent adjustments) defined a multi-tiered monitoring mechanism of health expenditure, debt settlement and recovery. In the event that the deficit in the management of the RHS persisting in the fourth quarter of the financial year surpasses some pre-defined caps (which have become stricter by 2010), the Region is considered to be in a situation of financial imbalance. Once that the excessive deficit is definetely assessed by a monitoring unit set up by the State-Regions Conference, the Prime Minister warns the Regions to take the necessary measures to ensure rebalancing by 30 April of the following year. Within 30 days the Region had to approve a recovery plan from the operating deficit, which has to be approved by the monitoring unit and the State-Regions Conference within the subsequent 45 days. If the plan has not been submitted or has been rejected by the State-Regions Conference, the Prime Minister (and the MEF) shall appoint a Commissioner to prepare the plan and its implementation. Moreover, a series of actions for the settlement of the deficit are activated, entailing the increase of the regional taxes, a total blocking in staff hiring and turnover and the ban of undertaking non-compulsory expenditures. In case of inertia of the Region, these measures are automatically triggered within 30 days from the appointment of the Commissioner. Following the approval of the debt recovery plan, the MEF allocates the 40% of additional resources deemed necessary for payoff. The

7 Law No. 311, 30 December 2004, “Disposizioni per la formazione del bilancio annuale e pluriennale 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 di Trento e Bolzano, 23 March 2005, “Intesa, ai sensi dell'articolo 8, comma 6, della legge 5 giugno 2003, 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).

162 The Italian NHS after the Economic Crisis: From Decentralization to Differentiated Federalism remaining 60% is granted on a quarterly and annual basis after assessment of the implementation of the plan. In 2007, the recovery plan was activated for seven Regions and other three were added in 2009 and 2010. Eight over ten Regions are still subject to this mechanism. These Regions include all Southern and Southern-Central Regions, except the small Basilicata, while only two Northern Regions were forced to approve a recovery plan and were never commissioned. One of the most delicate and most discussed passages of the recovery plan procedure was the appointment of a Commissioner. This role was attributed to the Governor of the commissioned Region itself, until this practice was banned in 2014. However, playing the role of Commissioner, even the Governor of the Region was highly restricted in its freedom to define health policy, being forced to implement decisions mostly taken by the MEF and central government. Moreover, the central government could also appoint Subcommissioners, chosen from persons of proven technical competence in the area of health. Despite differences between individual cases, the recovery plan mechanism was largely effective in securing a debt reduction of the Regions. Between 2009 and 2014, the deficit of 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 extremely difficult to abandon them. On the basis of the documentation available on the website of the Ministry of Health with regard to the single plans and their processes, and the information collected in some interviews, we can assume that this was due not only to the presence of particularly demanding financial targets in years of economic crisis, but also to the existence of objectives beyond purely economic aspects that impacted on quality and access to services. In many cases these objectives were not easy to meet, considering that recovery plans inevitably required retrenchment policies, which entailed severe cuts and other kind of restrictions in service provision. From the point of view of the inter-governmental relations, the recovery plan mechanism severely restricted the autonomy of Regional governments in the development of health policies, including those relating to service management and organization. Central government and, in particular, the MEF, directly or by means of the monitoring unit of the State-Regions Conference, not only exerted a penetrating supervision and monitoring of the plan implementations in the Regions concerned, but often 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 involve increased expenditure. Although the formal division of powers between the levels of government has not changed over the past decade, regional decentralization proved in

163 Stefano Neri fact to be much weakened in favour of an increase of the Central State’s regulatory role, embodied by MEF rather than by the Ministry of Health (Frisina-Doëtter and Neri, 2018a; 2018b). If Central and Southern-Central health care have been subjected to these strict forms of control during the years of crisis and until now, this has not been the case of the Northern 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 has allowed 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 from safeguarding, substantially, their autonomy in health care management and organization. The structural reforms of the Lombard and Tuscan health system adopted in recent years are two examples of the clear persistence of autonomous and unchanged powers compared to the past in the organization and regulation of services, by the Regions not subject to recovery plans. Moreover, some of these Regions (Emilia-Romagna, Lombardy and Veneto) have requested “particular forms and autonomy conditions” (Article 116, clause 3, Italian Constitution), both in the health sector and in other policy sectors, which would make them more similar to the five Italian Regions provided, from the 1950s, with a special autonomy for historical or ethnical reasons. This showed the will to move towards a more clearly oriented structure of powers in the federal sense. 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 – and the formal request of the Emilia-Romagna government between August and October 2017, a negotiating table was opened with the central government, according to the procedure laid down in Article 116 of the Italian Constitution. While negotiations are still underway in 2018 and 2019, other Regions requested greater autonomy. Although the contents required by the “greater autonomy” still have not been explicitly defined, it is quite clear that it should concern not only the management of resources but also regional tax capacity, today very limited, so as to take a significant step towards a more complete accountability of the Regions. The most delicate issue concerns the possibility to retain most of fiscal revenues collected within any single Region, limiting the process of central redistribution. Given the very relevant differences in fiscal capacity between the north and the south of Italy, the potential effects of this change could be highly detrimental for Southern Regions.

164 The Italian NHS after the Economic Crisis: From Decentralization to Differentiated Federalism

5. CONCLUSION The tendency to move towards a substantial recentralization of decision-making in national health policies with relevant impact of expenditure is linked to the need to respect the restrictions imposed by the process of European integration and Monetary Union and the globalisation of international markets, in a situation of a severe financial crisis. That condition has enhanced the role of central government, able to participate in decision making at supranational level and to influence economic dynamics and international finance, albeit with many limitations. In this sense, centralization seems to be determined primarily by factors exogenous to the health care system, which have to do with “external constraints” (Ferrera and Gualmini, 2004) to the Italian economic and welfare system. These constraints are not new, but in the last decade they acted with a strength and cogency unknown in the past. However, the re-affirmation of the role of the central State in the NHS depends also on factors endogenous to the health care system, such as the characteristics and shortcomings in the NHS governance, which were emphasized by the economic crisis. As we have described, the institutional framework that emerged after the 1990s had led to the construction of mechanism of joint policy making between the central government and the Regions based on the State-Regions Conference. This system has shown serious limits in conditions of economic crisis. The ability of the central government, even more than the Parliament, to determine ultimately the amount of NHS funding through legislation resulted in the affirmation of the prevalence of this level of government, highlighting the substantial supervision on financial resources from the centre. The imbalance in powers exercised in this field is also accentuated by severe limitations that exist in the Regional fiscal autonomy. In addition, central control, an element often overlooked, is not limited to financial resources but extends to the determination of the other major health sector inputs (labour, drugs, equipment, and medical devices), as highlighted by the austerity measures imposed by the Government in recent years. These trends were not limited only to the years of financial emergency arising from the sovereign debt crisis, but were manifested, in part, already earlier and somehow seemed to continue in more recent years, favoured by the persistent state of the Government’s financial difficulties due to the high public debt. In this sense, we can assume that they will continue, perhaps in a milder form, even under conditions of economic recovery. Other factors have contributed to the re-assertion of the role of the central government, such as the overwhelming incapacity of at least half of the Regions to manage the health system efficiently, as well as to guarantee adequate quality services, and also the legitimation crisis of the Regional institution.

165 Stefano Neri The story of the debt recovery plans and, at the same time, the request for greater autonomy from Northern Regions lead us to affirm that the NHS is not directed towards a simple re-centralization, at least in the regulation of the system, but rather towards a search on new balances between centralization and decentralization. The most probable hypothesis is that all this can lead to the end of the traditional distinction between five Regions provided with special autonomy and fifteen Regions provided with a uniform set of powers and responsibilities, in direction of a system of powers and responsibilities that differs according to the conditions of each Region or of different groups of Regions. On the substantive level, in fact, what happened in the last 10 years represents an evolution towards different forms of decentralization or federalism in the NHS. In the coming years, the change could find greater recognition also on a formal level. The evolution towards a “differentiated federalism” (Frisina-Doëtter and Neri, 2018a; 2018b) presents risks and opportunities for the NHS. On one hand, it responds to unquestionable territorial differences in the economic and financial resources, administrative tradition and capacity as well as population needs, which the previous NHS governance did not take into account. On the other hand, there is the serious risk that existing territorial differences will be exacerbated, thus further widening the gap between 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 are needed. First of all, the formal attribution of greater autonomy to Northern Regions will be devised by finding institutional and regulatory mechanisms able to ensure the principles of equity and solidarity which are at the base of the NHS. Second, the State will necessarily go beyond its current prevailing role of financial watchdog, in charge of implementing retrenchment policies, and actively help Regions with lower performances improve the quality of their health services by developing innovative forms of planning and cooperation. At the moment, both of these conditions seem far from being satisfied.

STEFANO NERI Dipartimento di Scienze Sociali e Politiche, Università degli Studi di Milano Via Conservatorio, 7, 20122 – Milano, Italia Contact: [email protected]

Received on 31.12.2018 Accepted for publication on 02.05.2019

166 The Italian NHS after the Economic Crisis: From Decentralization to Differentiated Federalism

REFERENCES ARAN – Agenzia per la Rappresentanza Negoziale delle Pubbliche Amministrazioni (2011), Rapporto semestrale sulle retribuzioni dei dipendenti pubblici. Roma: Servizio Studi Aran. Accessed on 29.12.2018, at https://www.aranagenzia.it/attachments/article/2041/Rapporto%20Semestrale%201- 2011.pdf. Arlotti, Marco; Ascoli, Ugo; Pavolini, Emmanuele (2018), “Une transformation structurelle en cours dans le système de santè italien: les fonds de santé”, in Gilles Ferréol (ed.), Systèmes de santé et politique de soins: vers de nouveaux défis? Louvain-la-Neuve: EME, 193-208. Asensio, Maria; Popic, Tamara (2019), “Portuguese Healthcare Reforms in the Context of Crisis: External Pressure or Domestic Choice?”, Social Policy & Administration. DOI: 10.1111/spol.12480 Bonoli, Giuliano; Natali, David (eds.) (2012), The Politics of the New Welfare State. Oxford: Oxford University Press. Bordignon, Massimo; Mapelli, Vittorio; Turati, Gilberto (2002), “Can We Fit a Square Object in a Round Hole? Fiscal Federalism and National Health Service in the Italian System of Governments”, in Annual Report on Monitoring Italy. Roma: ISAE – Istituto Studi e Analisi Economica, 37-125. Bordogna, Lorenzo; Neri, Stefano (2014), “Austerity Policies, Social Dialogue and Public Services, in Italian Local Government”, Transfer: European Review of Labour and Research, 20(3), 357-371. Carpani, Guido (2006), La Conferenza Stato-regioni. Competenze e modalità di funzionamento dall'istituzione ad oggi. Bologna: Il Mulino. Corte dei Conti (2016), “Rapporto 2016 sul coordinamento della finanza pubblica”. Accessed on 27.12.2018, at http://www.corteconti.it/export/sites/portalecdc/_documenti/controllo/sezioni_riunite/sezio ni_riunite_in_sede_di_controllo/2016/rapporto_coordinamento_finanza_pubblica_2016.p df. Enthoven, Alain C. (1985), Reflections on the Management of the National Health Service. London: Nuffield Provincial Hospitals Trust. Fargion, Valeria (2006), “Changes in the Responsibilities and Financing of the Health System in Italy”, Revue française des affaires sociales, 6, 271-296. Ferrera, Maurizio; Gualmini, Elisabetta (2004), Rescued by Europe?: Social and Labour Market Reforms in Italy from Maastricht to Berlusconi. Amsterdam: Amsterdam University Press. France, George; Taroni, Francesco (2005), “The Evolution of Health-Policy Making in Italy”, Journal of Health Politics, Policy and Law, 30(1-2), 69-188. Frisina-Doëtter, Lorraine; Neri, Stefano (2018a), “Redéfinir le rôle de l’État dans le soins de santé: une analyse comparative de l’Italie et des États-Unis”, in Gilles Ferréol (ed.), Systèmes de santé et politique de soins: vers de nouveaux défis? Louvain-la-Neuve: EME, 175-191.

167 Stefano Neri

Frisina-Doëtter, Lorraine; Neri, Stefano (2018b), “Redefining the State in Health Care Policy in Italy and the United States”, European Policy Analysis, 4, 234-254. France, George; Taroni, Francesco (2005), “The Evolution of Health-Policy Making in Italy”, Journal of Health Politics, Policy and Law, 30(1-2), 69-188. Giarelli, Guido (2017), “1978-2918: quarant’anni dopo. Il Ssn tra definanziamento, aziendalizzazione e regionalizzazione”, Autonomie locali e servizi sociali, 3, 455-482. Jones, Erik (2012), “Italy’s Sovereign Debt Crisis”, Survival: Global Politics and Strategy, 54(1), 83-110. León, Margarita; Pavolini, Emmanuele; Guillén, Ana Maria (2015), “Welfare Rescaling in Italy and Spain: Political Strategies to Deal with Harsh Austerity”, European Journal of Social Security, 2, 182-201. Light, Donald W. (1997), “From Managed Competition to Managed Cooperation: Theory and Lessons from the British Experience”, The Milbank Quarterly, 75(3), 297-341. Maino, Franca (2001), La politica sanitaria. Bologna: Il Mulino. Maino, Franca; Neri, Stefano (2011), “Explaining Welfare Reforms in Italy between Economy and Politics: External Constraints and Endogenous Dynamics”, Social Policy & Administration, 45(4), 445-464. Mapelli, Vittorio (2007), “I sistemi di governance dei servizi sanitari regionali”, Quaderni Formez, 57. Mapelli, Vittorio (2012), Il sistema sanitario italiano. Bologna: Il Mulino [2nd ed.]. Marangoni, Francesco; Tronconi, Filippo (2014), “La rappresentanza degli interessi in parlamento”, Rivista Italiana di Politiche Pubbliche, 9, 557-588. Ministero dell’Economia e delle Finanze (2018), Commento ai principali dati del Conto Annuale del periodo 2007-2016. Accessed on 28.12.2008, at https://www.contoannuale.mef.gov.it/. Natali, David; Pavolini, Emmanuele (2014), “Comparing (Voluntary) Occupational Welfare in the EU: Evidence from an International Research Study”, OSE Research Paper, 16. Neri Stefano (2011), “The Evolution of Regional Health Services and the New Governance of the NHS in Italy”, in Angus Douglas; Boutsioli Zoe (eds.), Health Studies: Economic, Management and Policy. Athens: Atiner, 269-282. Neri, Stefano (2012), “I fondi previdenziali e sanitari nel welfare aziendale”, La Rivista delle Politiche Sociali, 3, 129-44. Neri, Stefano; Pavolini, Emmanuele; Vicarelli, Giovanna (2017), “The Italian NHS in the Era of Austerity: Is a ‘Gradual Transformation’ Taking Place?”. Paper presented at The LSE International Health Policy Conference, 16-19 February, London, United Kingdom. Pavolini, Emmanuele; Guillén, Ana Marta (eds.) (2013), Health Care Systems in Europe Under Austerity: Institutional Reforms and Performance. Basingstoke: Palgrave. Pavolini, Emmanuele; Lèon, Margarita; Guillén, Ana Marta; Ranci, Costanzo (2015), “From Austerity to Permanent Strain?”, Comparative European Politics, 13(1), 56-76. Pavolini, Emmanuele; Vicarelli, Giovanna (2012), “Is Decentralization Good for Your Health? Transformations in the Italian NHS”, Current Sociology, 60(4), 472-488.

168 The Italian NHS after the Economic Crisis: From Decentralization to Differentiated Federalism

Sarti, Simone (2017), “Salute e crisi: convergenze e divergenze nei sistemi regionali tra il 2005 e il 2013”, Autonomie locali e servizi sociali, 2, 201-220. Sarti, Simone; Terraneo, Marco; Tognetti, Bordogna Mara (2017), “Poverty and Private Health Expenditures in Italian Households during the Recent Crisis”, Health Policy, 121(3), 307- 314. Sotiropoulos, Dimitri A. (2015), “Southern European Governments and Public Bureaucracies in the 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-South Gap”, Health Economics, Policy and Law, 9(3), 231-249. Toth, Federico (2016), “The Italian NHS, the Public/Private Sector Mix and the Disparities in Access to HealthCare”, Global Social Welfare, 3, 171-178. Vicarelli, Giovanna (2015), “Healthcare: Difficult Paths of Reform”, in Ugo Ascoli; Emmanuele Pavolini (eds.), The Italian Welfare State in a European Perspective. Bristol: Policy Press, 157-178. Vicarelli, Giovanna; Pavolini, Emmanuele (2015), “Health Workforce Governance in Italy”, Health Policy, 119(12), 1606-1612.

169 e-cadernos CES, 31, 2019: 170-193

ROSSELLA DE FALCO

ACCESS TO HEALTHCARE AND THE GLOBAL FINANCIAL CRISIS IN ITALY: A HUMAN RIGHTS

PERSPECTIVE

Abstract: Equitable access to healthcare is fundamental in preventing health inequities, and it is warranted by 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 article analyses this process through the case study of Italy, where the 2008 Great Recession catalysed a series 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 downsized health staff and facilities, combined with reduced disposable income, was associated with a drastic rise in inequities in accessing healthcare in Italy. Keywords: access to healthcare; austerity; health inequities; Italy; right to health.

ACESSO A CUIDADOS DE SAÚDE E A CRISE FINANCEIRA GLOBAL EM ITÁLIA: UMA PERSPETIVA

DOS DIREITOS HUMANOS

Resumo: O acesso equitativo aos cuidados de saúde é fundamental na prevenção das injustiças na saúde e é garantido por normas internacionais e regionais sobre direitos socioeconómicos. No entanto, durante uma crise financeira, a austeridade fiscal pró-cíclica pode transferir o custo dos cuidados de saúde do público para o indivíduo, afetando o direito de todos ao acesso adequado a cuidados de saúde. Este artigo analisa este processo através do estudo de caso da Itália, onde a Grande Recessão 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 saúde autorrelatadas, será demonstrado que o aumento das taxas de utilizador e a redução das equipas e das instalações de saúde, combinados com a redução do rendimento disponível, estiveram associados a um aumento drástico das desigualdades no acesso aos cuidados de saúde em Itália. Palavras-chave: acesso aos cuidados de saúde; austeridade; injustiças na saúde; direito à saúde; Itália.

170 Rossella De Falco

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 fiscal policies, increasing spending and rising taxes to revive aggregate demand. Supported by the International Monetary Fund (IMF) 37 countries (accounting for around 73% of the 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 increased public debts. As a consequence, many governments turned to harsh austerity measures to restore public finances, either out of their own volition or under pressure from regional banks and international financial institutions (IFIs). Even if the rise in public deficits was largely a result of the crisis, the international community began looking at welfare states with suspicion, blaming overly generous welfare benefits for the global financial meltdown (ibidem). In this way, policies such as horizontal budget cuts, regressive reforms and large-scale privatisation became the new normal in policy-making circles, causing widespread socio-economic malaise in developed and non-developed countries alike (Chakrabortty, 2016). Austerity measures can also result in socioeconomic rights’ backsliding, with the most vulnerable groups bearing the heaviest burden of fiscal adjustment. In these particularly severe cases, economic recovery policies might constitute a prima facie violation of the International Covenant on Economic, Social and Cultural Rights – ICESCR (United Nations, 1967). As many other fundamental rights, the right to health has been sternly affected by regressive fiscal measures. This is not surprising, as healthcare often occupies a huge share of public expenditure in most welfare states, and many governments reduced their health budgets (Mackenbach, 2013). This policy pattern was followed by the Italian government as well, with huge repercussions on healthcare accessibility. In fact, if progressive health policies, combined with inclusive social policies, can improve healthcare affordability, horizontal cuts might hinder equitable access to care (Sabine, 2016). Consistently, several waves of austerity undertaken by the Italian government are 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 or contracted a medical debt (CENSIS/RBM, 2018). In other words, the United Nations Committee on Economic, Social and Cultural Rights is fully backed by hard evidence when 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 global financial crisis exacerbated inequities in access to care throughout Italy. Thus, this

171 Access to Care and the Global Financial Crisis in Italy: A Human Rights Perspective work 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 through article 32 of its Constitution (Italian Republic, 1947). To this end, disaggregated European Union Statistics on Income and Living Conditions (EU-SILC) microdata on unmet medical needs will be scrutinised in detail, highlighting how disparities in accessing care have widened during the crisis. These data are disaggregated by socio-economic status, labour status, education attainment level as well as country of citizenship and of birth. Special attention will be also given to geographical differences between 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 have been widely discussed by heterodox and orthodox economists alike (Krugman, 2015; Stiglitz apud Hackwill, 2016). Bearing this in mind, the conclusions of this work will summarise 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 AT TIMES OF ECONOMIC CRISIS:

A HUMAN RIGHTS FRAMEWORK Equitable access to healthcare is one of the tenants of the right to the highest attainable standard of physical and mental health. In fact, article12 of the ICESCR obliges member states to take steps towards “the prevention, treatment and control of epidemic, endemic, occupational and other diseases” as well as “the creation of conditions which would assure to all medical service and medical attention in the event of sickness” (United Nations, 1967: 6-7). Equitable access to healthcare, thus, is dependent upon the dimensions of availability and accessibility of healthcare goods and facilities (United Nations, 2000). Availability relates to the existence of healthcare facilities and essential medicines in proper quantity and of acceptable quality (ibidem). Accessibility, instead, is a multidimensional principle composed of the following elements: physical accessibility; economic accessibility (i.e. affordability); non-discrimination; and information accessibility.1 In Europe, the warranty of fair and universal access to high-quality and timely healthcare is also provided by the Charter of Fundamental Rights of the European Union (European Union, 2012) and the European Social Charter (Council of Europe,1996).

1 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 Nations Committee on Economic, Social and Cultural Rights in its General Comment 14 (UN – CESCR 2000)

172 Rossella De Falco Notwithstanding the plethora of norms ensuring access to care, barriers in accessing healthcare are widespread across European countries. This is concerning, as equitable access to care is a key factor in preventing health inequities. In fact, if the promotion of the underlying determinants of health diminish socio-economic disparities in contracting an illness, enabling access to health eases inequities in surviving and healing from diseases (Costa, 2017). Therefore, to ensure the progressive realisation of the right to health and to combat health inequities, it is urgent to ensure that all individuals have universal access to timely care, with special attention to vulnerable groups. Which factors cause inequality in accessing care? First, high levels of income inequality within socio-economic groups can result in massive health inequities. In fact, people living in poverty, or experiencing precarity on low-paid jobs, might forego care due to financial reasons. In “The Killing Fields of Inequality”, Therborn (2012) defines these kinds of socio-economic disparities as inequality “of resources”. Likewise, individual differences such as age, gender, nationality and country of birth can all generate significant gaps when accessing healthcare. These inequalities are defined as “existential” by Therborn (ibidem). Finally, regressive health policies might also undermine equitable access to care. For example, the 2008’s global financial crisis has prompted an increase of people lamenting unmet healthcare needs in the EU (Baeten et al., 2018). This might be the result of the harsh austerity measures implemented in Europe after the global recession, with loss of entitlements for some groups and, at the same 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, structural inequalities and access to care through the case-study of a high-income Mediterranean country: Italy. In fact, Italy was hardly hit by the economic crisis, with severe repercussions on its healthcare system. After depicting the major healthcare reforms that followed the global financial crisis, inequitable access to healthcare is analysed through 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 within the EU-SILC survey, and they are freely accessible at aggregate level. Special attention will be given to the effect of being either a poor or a working poor on accessing healthcare. For the individuals that are excluded from official data, such as illegal migrants, qualitative data

173 Access to Care and the Global Financial Crisis in Italy: A Human Rights Perspective will be used. As for data regarding geographical health inequities, the point of reference is the Italian National Statistics Office’s database Health for All.2 As regards the theoretical premises underpinning the present work, this article builds on the vast literature on human rights measurement (Barsh, 1993; Landman and Carvalho, 2009; Ramirez, 2011; Hunt et al., 2013) as well as health equity (Diderichsen et al., 2001).

4. THE ITALIAN NATIONAL HEALTH SERVICE (NHS): A SYSTEM UNDER THREAT The Italian NHS (Servizio Sanitario Nazionale – SSN) was founded in 1978, replacing the pre-existing social health insurance system. Based on the principles of universality, solidarity and financial protection, the system is funded by general taxation and provides automatic coverage to all citizens, legal foreign residents and migrants holding a residence permit. Thus, the institution of the Italian NHS realised, in principle, both the collective and the individual dimensions of the right to health, as enshrined by article 32 of the Italian Constitution. In fact, this article warrants that the right to health is “a fundamental right of the individual” as well as a “collective interest”, enabling “free medical care to the indigent” (Constitution of the Italian Republic, 1947, art. 32). For years, this three-tiered system has delivered free, high-quality healthcare to those in 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 gap between Northern and Southern regions, combined with financial constraints plaguing the most vulnerable groups. However, subsequent reforms focused more on cost containment rather than easing health inequities. In fact, only ten years after the SSN was founded, user fees were introduced aside general taxation as an instrument to regulate healthcare demand and increase the efficiency of the system (Decree-Law 382/1989).3 By the same token, potential measures that impinged on health equity were introduced with law 347/2001,4 which established that single Italian regions can set different rules on user fees due to budget reasons. The gradual shift of health costs from the state to the individual has been further aggravated by the introduction of an additional fee on specialist visits (Decree-Law 111/2011;5 Cittadinanzaattiva, 2011).

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 sul ripiano 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 on 01.12.2019 at http://www.parlamento.it/parlam/leggi/decreti/01347d.htm. 5 Decree-Law 111/2011, “Conversione in legge, con modificazioni, del decreto-legge 6 luglio 2011, n. 98 recante disposizioni urgenti per la stabilizzazione finanziaria (11G0153) (GU Serie Generale n.164 del 16- 07-2011)”. Accessed on 02.12.2019, at https://www.gazzettaufficiale.it/eli/id/2011/07/16/011G0153/sg.

174 Rossella De Falco This is 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 GLOBAL PHENOMENON Before proceeding with the analysis of Italian health reform policies, it is necessary to link Italy’s decisions in policy making with the broader global turn towards spending contraction. Since 2010, in fact, most governments around the world have been implementing 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 rise slightly in 2020 (Ortiz et al., 2015: 2-6). This short-term adjustment process is supposed to affect nearly 80% of the global population (ibidem). Moreover, by 2020, an estimated 30% of countries in the world will be undergoing excessive fiscal contraction, defined as cutting public expenditures below pre-crisis levels, including countries with high developmental needs such as Angola, Eritrea, Iraq, Sudan and Yemen (ibidem). As shown in Table 1, contractionary fiscal policies can be implemented either by reducing spending or increasing revenues. Measures aimed at reducing spending include budget cuts, regressive tax changes, labour reform and pension reform. Although less often implemented, outsourcing and privatisation have also been used by governments 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 • Increasing taxes on goods and • Rationalizing and further targeting services (mostly Value added social safety nets Taxes – VATs) • Healthcare reforms • Privatisation of Public Services • Old-age pensions reforms

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 Italy also began decreasing over the period 2008-2010. At the same time, as shown in Figure 1, private healthcare spending started increasing. This shift in public and private shares of healthcare costs will be now analysed in detail over the next paragraphs.

175 Access to Care and the Global Financial Crisis in Italy: A Human Rights Perspective

FIGURE 1 – Public (GDP, %) vs. Private Healthcare Spending (Current Health Expenditure – CHE, %), Italy

6,2 41 6,1 40,5 6 40 5,9 5,8 39,5 5,7 39 5,6 38,5 5,5 38 5,4 5,3 37,5 5,2 37 2007 2008 2009 2010 2011 2012 2013 2014 2015

Domestic General Expenditure (%GDP)

Domestic Private Health Expenditure (% of Current Health Expenditure)

Source: Elaboration by the author from OECD – Organisation for Economic Co-operation and Development (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 AUSTERITY MEASURES Italy’s economic growth was already stagnant when the sovereign debt crisis struck the Eurozone. Additionally, Italy’s public debt grew from 103% in 2007 to nearly 127% in 2012 (Petrelli, 2013). This escalation of the public debt compromised mutual trust between 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 of contagion spread among the other major European economies. In fact, if the third largest European economy ended like Greece, the stability of the whole Eurozone would have been severely compromised. On 5 August 2011, the Italian government received a letter by European Central Bank’s leaders Mario Draghi and Jean-Claude Trichet. The letter was an offer of debt financing by the European Central Bank (ECB), given the implementation of the following reforms: large-scale privatisation; transferring of collective bargaining to undertakings; public sector pay-cuts; privatisation of public utilities; introduction of automatic correction mechanisms for deficits (Fischer-Lescano, 2014). Therefore, Italy’s implementation of austerity policies was not the result of direct economic conditionalities attached to international rescue loans, as in the case of the Memorandum of Understandings (MoUs) signed by Greece with the institutions of the Troika (IMF, World Bank, and the ECB).

176 Rossella De Falco Rather, Italy reacted to an open letter by the ECB. The letter was made public by several newspapers, but it was not intended as an official document (Corriere della Sera, 2011). Because of the letter, then-Prime Minister Silvio Berlusconi resigned. Soon after, in 2011, a bipartisan governmental coalition guided by the renowned academic and economist Mario Monti implemented a series of policy 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)

7,100

7,00

6,900

6,800

6,700

6,600

6,500

6,400

6,300

6,200 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Source: Elaboration by the author from OECD – Organisation for Economic Co-operation and Development (2019), “OECD Health Statistics 2019”, July 2. Accessed on 02.12.2019, at http://www.oecd.org/els/health-systems/health-data.htm.

Over the 2008-2010 period, Italy froze public spending on health. In fact, the average annual growth of health spending was 6% between 2000 and 2007, but only 2.3% over the period 2008-2010 (La Repubblica, 2013). As shown in Figure 2, in 2010, Italian health spending abandoned its decennial positive trajectory and began a gradual, yet steady, decrease (DEF, 2017). At the same time, funds for essential medicines and the National Health 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 Italian Ministry of

6 See Stability Law 228/2012, “Disposizioni per la formazione del bilancio annuale e pluriennale dello 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.

177 Access to Care and the Global Financial Crisis in Italy: A Human Rights Perspective Economics and Finance has recently predicted that health spending will further 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 health spending with those of the rest of Europe. In fact, Italy performs far worse than countries 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 of healthcare have impacted multiple dimensions of the right to health: accessibility, availability, quality and acceptability. As this paper is concerned with equitable access to care, only the dimensions of accessibility and availability of healthcare will be 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 of OOPs 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 of healthcare systems. Empirical research has also shown that, at global level, the less a government 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)

24 7,2 23,5 7 23 22,5 6,8

22 6,6 21,5 21 6,4 20,5 6,2 20 6 19,5 19 5,8 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Out-of-pocket (OOPs), % of Health Spending (total) Public Spending on Health, % of GDP

178 Rossella De Falco 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 six years of fiscal contraction, the percentage of OOPs reached 23%, or one fifth of the overall expenditure on health (OECD and European Observatory on Health Systems and Health 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 and doubling those of France. This is clearly shown in Figure 4.

FIGURE 4 – Public Health Expenditure, % of GDP, Selected European Countries (2014)

Germany 9,5 Denmark 9,2 France 8,7 Norway 8,5 EU28 7,9 UK 7,9 Finland 7 Italy 6,7 Spain 6,5 Portugual 5,9 Greece 4,8 Poland 4,4 0 5 10

Source: Elaboration by the author from: OECD – Organisation for Economic Co-operation and Development (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 a common source of discontent among all European citizens. Excessively long waiting times can also foster inequities in accessing care, as high-income patients tend to bypass waiting lists in the public sector by consulting a private specialist, paying additional fees (Baeten et al., 2018). Likewise, informal, under-the-table payments are a common practice in several European countries (ibidem). On a similar pace, excessive waiting lists have been widely documented throughout Italy by independent agencies (CENSIS/RBM, 2018). However, states have started collecting data on waiting lists only recently. Therefore, a systematic diachronic analysis is not possible in this case. As it can be seen from Table 2 and Table 3, in any case, average waiting times (in days) have been rapidly growing over the 2014-2017 period, according to an independent investigation by CENSIS/RBM (ibidem). Table 3 also shows

179 Access to Care and the Global Financial Crisis in Italy: A Human Rights Perspective different waiting times for private and public facilities, unveiling huge discrepancies. This data, however, have the limitation of coming from a report of two private 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

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 or costs associated to travel longer distances. This is a risk for Italy, where both hospitals and hospital beds have been significantly downsized during the crisis. In fact, hospitals went 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 in 2017. In Italy, however, this negative trend, however, initiated far before the crisis.9

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 (last accessed on 02.12.2019). Indicator Name: OECD (2019), Hospital beds (indicator). DOI: 10.1787/0191328e-en

180 Rossella De Falco

4.5. IMPACT ON ACCESS TO HEALTHCARE: WIDENED INEQUITIES Horizontal budget cuts had a substantial impact on access to healthcare. However, the impact has been far more severe for the more disadvantaged groups in the Italian society, whereas those that were already better-off were barely touched from the crisis regarding their access to healthcare. This section investigates in detail how differences in terms of socioeconomic, labour, education attainment status and country of origin are 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 for lower income groups. Moreover, medium and low-income patients face severe barriers in accessing healthcare timely when the public sector is plagued by excessively long waits (Landi, 2013; Petrelli et al., 2012). Bearing this in mind, this section explores how socioeconomic status can determine unequal access to healthcare at times of crisis. As Figure 5 shows, the impact of regressive fiscal consolidation measures has been unevenly 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”, by Income Quintile (% of the total population), Italy, 2008-2017

18,00 16,00 14,00 12,00 10,00 8,00 6,00 4,00 2,00 ,00 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Total 1st Quintile 5th Quintile

Source: Elaboration by the author from Eurostat, “European Union Statistics on Income and Living Conditions (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 of people in the lowest quintile suffering from unmet medical needs had been steadily growing, becoming as high as 15.5% in 2015. By contrast, the number of people in the

181 Access to Care and the Global Financial Crisis in Italy: A Human Rights Perspective highest quintile reporting foregone care was below 1% over the period 2008-2017 and it has also diminished during the period of the crisis. Clearly, the most vulnerable socioeconomic group was bearing the heaviest burden of contractionary fiscal policies. Reinforcing this evidence, a recent study has yielded that, in Italy, people that are at risk of poverty or experience severe material deprivation are more likely to renounce to healthcare (Gaudio et al., 2017). Moreover, the likelihood is higher for people living in the Islands, in the South and for foreigners (ibidem).

TABLE 4 – Unmet Needs for Dental Care, “Too Expensive”, (%), Difference between Pre and Post Crisis 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. In Table 4, it can be seen that unmet needs for dental care due to financial reasons rose by almost 3% for the poorest income quintile, while they even reduced by 0.5% for the better-off.

FIGURE 6 – Unmet Needs for Dental Care, ‘Too Expensive, Far to Travel or Waiting List’, by Income Quintile, Italy, % of Total Population

25,0

20,0

15,0

10,0

5,0

0,0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

5th Quintile 1st Quintile Total

182 Rossella De Falco Figure 6, instead, shows unmet needs for dental care due to all reasons over time. The figure shows that, in 2008, 14.6% of the Italians in the poorest quintile could not afford dental 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 access barrier for dental care. In fact, according to a report by the Italian National Statistics Office, only 29.2% of people aged 75+ accessed dental care in 2015, against the European average 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 in access to healthcare; this because the amount of occupational welfare benefits depends strongly on companies’ characteristics such as size and productivity and can galvanize health inequities when it comes to access healthcare services (Baeten et al., 2018). Troublingly, voluntary and occupational health insurance may also lead to shortage of public healthcare, as they encourage NHS’ doctors to join the private sector (ibidem).

FIGURE 7– Unmet Needs for Healthcare, “Too Expensive, Far to Travel or Waiting List”, Unemployed vs Employed Persons, % of people aged 55 to 64, 2008-2017, Italy

30,0

25,0

20,0

15,0

10,0

5,0

0,0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Unemployed Employed

Figure 7 displays that, during the crisis, the proportion of Italian unemployed people declaring unmet medical needs is much higher than employed persons. For example, in 2008, unmet medical needs for unemployed people aged 55-64 were three times higher than those of employed ones. This inequality has widened over time the period 2008- 2017, with employed people showing only a minor increase.

183 Access to Care and the Global Financial Crisis in Italy: A Human Rights Perspective

4.5.3. EDUCATIONAL ATTAINMENT The level of education can hugely influence access to care too. For example, lack of information and social networks can limit the auto-detection of severe illnesses. It has been proven, in fact, that for lack of knowledge, marginalisation and lack of social support’s networks can delay essential surgical operations such as hip replacement or cataract (Petrelli et al., 2012).

TABLE 5 – Unmet Needs for Medical Care, “Too Expensive, Far to Travel or Waiting List”, by Level of Educational Attainment, (%),2014, Italy

Medical Dental Mental Prescribed Total care care healthcare medicines

People with Primary Level of Education or 19,9 14,6 17,9 3,7 8,9 Less

People with Tertiary 10,5 7,4 8,8 2,6 4,5 Level of Education

Table 5 summarises EU-SILC survey data for 2014, disaggregated by level of education attainment. Individuals with lower levels of education lament higher unmet medical needs in comparison to those that accomplished higher levels of education, such as a university degree. Under EU-SILC, the education attainment levels of survey respondents are classified according to the 'International Standard Classification of Education', version of 2011 (UIS, 2012), so that data are harmonised for comparison between different countries.10

4.5.4. COUNTRY OF CITIZENSHIP The Italian NHS offers free medical care to all legal residents and migrants holding a permit.11 However, Italian citizens and foreigners access healthcare differently, according to Eurostat’s data. As it is shown in Figure 8, these differences widened throughout the crisis, skyrocketing in 2015, while remarkably easing in 2017.

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.

184 Rossella De Falco

FIGURE 8 – Unmet Needs for Medical Care, by Citizenship, “Too Expensive, Far to Travel or Waiting List”, (%), Italy

16,0 14,0 12,0 10,0 8,0 6,0 4,0 2,0 0,0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Foreign Reporting Country

Similar trends are observed when looking at the country of birth, rather than citizenship. In fact, access barriers lamented by those being born in another country are on average higher with respect to those having a different citizenship. These trends are shown for years 2008-2017 in Figure 9.

FIGURE 9 – Unmet Needs for Medical Care, by Country of Birth, “Too Expensive, Far to Travel or Waiting List”, (%), Italy

18,0 16,0 14,0 12,0 10,0 8,0 6,0 4,0 2,0 0,0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Foreign Italy

185 Access to Care and the Global Financial Crisis in Italy: A Human Rights Perspective Potential barriers in accessing healthcare services by the migrant population may be related to cultural differences, communication problems, administrative barriers as well 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, there are some groups that are totally excluded from public health services, and that do not figure in officials’ statistics. This is the case of the migrants not holding a residence permit, who are being increasingly marginalised, facing extremely high costs in terms of morbidity and mortality. There are also some migrants that hold a residence permit but 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 in the case of “economic” migrants (MSF, 2018). According to a leading medical non-governmental organization (ibidem), these individuals are deprived not only of the right 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 risks and access barrier are the Roma and Cinti ethnic minorities. Although these people have legal access to the services, strong barriers remain when it comes to the use of their right to timely health care (European Commission, 2004). For all these minorities present on the Italian territories, the economic crisis represents a source of concern because of the populist parties, which ride the wave of popular discontent and galvanise 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 many regional systems. To avoid widespread financial failure, the government required overspending 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 required to address the structural determinants of healthcare costs in their territories.12 Combined with successive austerity measures, this fragmentation of the Italian NHS 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, are struggling to meet the minimum levels of assistance (LEAs) guaranteed by law (Grazzini, 2018). The percentage of people satisfied with healthcare treatments embodies the gap between Northern and Southern regions in Italy. For example, in 2013, 65.3% of people in the South declared they were satisfied of their last specialist visit, against the 77.2% in the North (ISTAT, 2015b). The gap widens consistently when looking at satisfaction for

12 Piemonte, Liguria, Abruzzo, Molise, Campania, Lazio, Puglia, Calabria, Sicilia and Sardegna.

186 Rossella De Falco sanitation services inside hospitals, with 51% of the population 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 be observed regarding the satisfaction from medical and nursery assistance during hospitalisation (ibidem).

FIGURE 10 – People Satisfied with Hospitals’ Sanitation, North-South Divide, Italy (%)

80 70 60 50 40 30 20 10 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

South North

Source: Elaboration by the Author from ISTAT, Annual Report (ISTAT, 2015b)

FIGURE 11 – People Satisfied by Medical Assistance during Hospitalisation, North-South Divide (%)

90 80 70 60 50 40 30 20 10 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

South North

Source: Elaboration by the Author from ISTAT, Annual Report (ISTAT, 2015b)

These differences can be also seen through health expenditure per capita. In Table 6, it can be seen that health expenditure per capita in the Northern regions are higher

187 Access to Care and the Global Financial Crisis in Italy: A Human Rights Perspective than in Southern ones. Moreover, Table 6 shows that this indicator has increased over the 2008-2016 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 period in Italy. Furthermore, disadvantaged groups also lament higher levels of unmet medical needs when disaggregating by: socioeconomic, labour and educational attainment status; country of citizenship and origin; age; geographical provenience. Draconian austerity 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 of its citizens (Bilchitz, 2014; Salomon, 2015). According to human rights law, austerity measures, resulting in severe socioeconomic rights’ 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 orthodox economists alike (Stiglitz apud Hackwill, 2016; Krugman, 2015). In Europe, the cases of countries such as Iceland, Switzerland and Portugal (after 2013) show how economic recovery can be realised in line with international human rights law, without renouncing to efficiency and financial viability. Looking at the Italian economy, alternatives to austerity to reduce the debt-to-GDP ratio or to boost revenues include: financing at least a segment of the sovereign debt through bank loans, instead of financial markets’ lending (Werner, 2014); combating fiscal evasion, increasing the progressivity of the Italian taxation system, sheltering low and middle-income households from the worst impacts of the crisis. Thus, if many alternatives to harsh regressive measures do exist, it might be that some of the economic recovery policies undertaken by the Italian government were another deliberate “assault on universalism” (McKee and Stuckler, 2011: 1).

188 Rossella De Falco

ROSSELLA DE FALCO Human Rights Center “Antonio Papisca”, Università degli Studi di Padova Via Martiri della Libertà, 2, 35137 Padova, Italia Contact: [email protected]

Received on 20.01.2019 Accepted for publication on 23.06.2019

REFERENCES Baeten, Rita; Spasova, Slavina; Vanhercke, Bart; Coster, Stéphanie (2018), “Inequality in Access to Healthcare: A Study of National Policies”, in European Social Policy Network (ESPN). Brussels: Directorate-General for Employment, Social Affairs and Inclusion, European Commission. Accessed on 20.05.2019, at https://publications.europa.eu/en/publication- detail/-/publication/aff4d623-e7c2-11e8-b690-01aa75ed71a1/language-en. Barsh, Russell Lawrence (1993), “Measuring Human Rights Problems of Methodology and Purpose”, Human Rights Quarterly, 87, 107-109. Bilchitz, David (2014), “Socioeconomic Rights, Economic Crisis, and Legal Doctrine”, I.CON, 12(3), 710-739. Blanchard, Olivier (2008), “Blanchard Sees Global Economy Weathering Financial Storm”, IMF Survey Magazine. Accessed on 20.01.2019, at https://www.imf.org/external/pubs/ft/survey/so/2008/int090208a.htm?mod=article_inline. Camilli, Annalisa (2018), “Fuori Campo: Perché I Migranti finiscono nei Ghetti”, Internazionale. Accessed on 03.01.2019, at https://www.internazionale.it/reportage/annalisa- camilli/2018/02/08/fuori-campo-migranti-ghetti. CENSIS/RBM (2018), “VIII Rapporto RMB – CENSIS: sulla Sanità Pubblica, Privata ed Intermediata”. Accessed on 10.01.2019, at http://www.welfareday.it/pdf/VIII_Rapporto_RBM-Censis_SANITA_def.pdf. CESR – Center for Economic and Social Rights (2018), “Assessing Austerity: Monitoring the Human Rights Impact of Fiscal Consolidation”. Accessed on 01.12.2019, at: http://www.cesr.org/sites/default/files/Austerity-Report-Online2018.FINAL_.pdf. Chakrabortty, Aditya (2016), “Austerity is Far More than just Cuts. It’s about Privatising Everything We Own”, The Guardian. Accessed on 20.01.2019, at: https://www.theguardian.com/commentisfree/2016/may/24/austerity-cuts-privatising- george-osborne-britain-assets. Cittadinanzaattiva (2011), “Salute, ‘Superticket’”, September 29. Accessed on 17.01.2019, at https://www.cittadinanzattiva.it/faq/salute/1861-superticket.html. Corriere della Sera (2011), “C’è l’esigenza di misure significative per accrescere il potenziale di crescita”. Accessed on 18.01.2019, at https://www.corriere.it/economia/11_settembre_29/trichet_draghi_italiano_405e2be2- ea59-11e0-ae06-4da866778017.shtml.

189 Access to Care and the Global Financial Crisis in Italy: A Human Rights Perspective

Costa, Giuseppe (coord.) (2017), L’Italia per l’Equità nella Salute. Roma: Italian Ministry of Health/AGENAS/INMP/ISS/AIFA. Council of Europe (1996), “European Social Charter (Revised version)”, European Treaty Series, 163. De Belvis, Antonio Giulio; Ferré, Francesca; Specchia, Maria Lucia; Valerio, Luca; Fattore, Giovanni; Ricciardi, Walter (2012), “The Financial Crisis in Italy: implications for the Healthcare Sector”, Health Policy, 106(1), 10-16. De Vogli, Roberto (2013), “Financial Crisis, Austerity, and Health in Europe”, The Lancet, 382(9890), p. 391. De Vogli, Roberto (2014), “The Financial Crisis, Health and Health Inequities in Europe: The Need for Regulations, Redistribution and Social Protection”, International Journal for Equity in Health, 13, 58. DEF – Documento di Economia e Finanza (2017), “Analisi e tendenze della finanza pubblica”. Accessed on 22.05.2019, at http://www.rgs.mef.gov.it/_Documenti/VERSIONE-I/Attivit-- i/Contabilit_e_finanza_pubblica/DEF/2017/Sez-II- AnalisiETtendenzeDellaFinanzaPubblica.pdf. Diderichsen, Finn; Evans, Timothy; Whitehead, Margaret (2001), “The Social Basis of Disparities in Health”, in Timothy Evans; Margaret Whitehead; Finn Diderichsen; Abbas Bhuiya; Meg Wirth (eds.), Challenging Inequities in Health: From Ethics to Action. New York: Oxford University Press, 12-23. European Commission (2004), “Comunità ROM e Salute in Italia”. Madrid: Fundació Secretariado Gitano. Accessed on 02.01.2019, at http://ec.europa.eu/health/ph_projects/2004/action3/docs/2004_3_01_manuals_it.pdf. European Union (2012), “Charter of Fundamental Rights of the European Union – 2012/C 326/02”, Official Journal of the European Union, October 26. Fischer-Lescano, Andreas (2014), “Human Rights in Times of Austerity Policy: The EU Institutions and the Conclusion of Memoranda of Understanding”. Bremen: Nomos Verlagsgesellschaft. Accessed on 22.05.2019, at https://www.etui.org/content/download/13817/113830/file/Legal+Opinion+Human+Rights +in+Times+of+Austerity+Policy+(final).pdf. Gabriele, Stefania (2015), “Crisi, austerità, sistemi sanitari e salute nei Paesi dell’Europa meridionale”, Meridiana, 83, 63-90. Accessed on 01.02.2019, at www.jstor.org/stable/43575508. Gaudio, Raffaella; Camilloni, Laura; Di Napoli, Anteo; Gargiulo, Lidia; Costanzo, Gianfranco; Petrelli, Alessio (2017), “Povertà e Rinuncia a Visite Specialistiche o Trattamenti Terapeutici in Italia: Evidenze dall’Indagine EU-SILC”. Summary of studies presented at the XLI Conference of the Italian Association of Epidemiology, 25-27 October, Mantova, Italia. Grazzini, Enrico (2018), “Debito pubblico: per ridurlo lo Stato deve finanziarsi con le banche non sui mercati”, blog Il Fatto Quotidiano. Accessed on 20.01.2019, at

190 Rossella De Falco

https://www.ilfattoquotidiano.it/2018/02/22/debito-pubblico-per-ridurlo-lo-stato-deve- finanziarsi-con-le-banche-non-sui-mercati/4178782/. Hackwill, Robert (2016), “Austerity Obsession is Pushing EU into Crisis Warns Stiglitz”, Euronews, October 6. “Global Conversation”, Joseph Stiglitz interviewed by Oleksandra Vakulina. Accessed on 02.01.2019, at https://www.euronews.com/2016/10/06/obsession- with-austerity-pushing-eu-into-crisis-warns-stiglitz. Hernández-Quevedo, Cristina (2012), “Inequalities in Health and Equity in Access to Health Care Services by the Immigrant Population”. Paper presented at the 4th Conference on Migrant and Ethnic Minority Health in Europe, 21-23 June, Università Commerciale Luigi Bocconi, Milano, Italia. Accessed on 10.01.2019, at https://www.unibocconi.it/wps/wcm/connect/eb7723ab-d9da-4ebf-8e7d- 3e9bd6ad0e39/Plenary+4+-+Hernandez+(2).pdf?MOD=AJPERES. Hunt, Paul; de Mesquita, Judith Bueno; Lee, Joo-Young; Way, Sally-Anne (2013), “Implementation of Economic, Social and Cultural Rights”, in Nigel Rodley; Scott Sheeran (eds.), Routledge Handbook of International Human Rights Law. London: Routledge Handbooks. Israel, Sabine (2016), “How Social Policies Can Improve Financial Accessibility of Healthcare: A Multi-Level Analysis of Unmet Medical Need in European Countries”, International Journal for Equity in Health, 15. DOI: 10.1186/s12939-016-0335-7 ISTAT – Istituto Nazionale di Statistica (2015a), “Condizioni di Salute e Ricorso ai Servizi Sanitari in Italia e nell’Unione Europea”, Indagine Ehis 2015. Accessed on 03.01.2019, at https://www.istat.it/it/archivio/204655. ISTAT – Istituto Nazionale di Statistica (2015b), Rapporto Annuale 2015. Accessed on 03.01.2019, at https://www.istat.it/it/files/2015/05/Rapporto-Annuale-2015.pdf. Italian Republic (1947), The Constitution of the Italian Republic. Gazzetta Ufficiale, 27 dicembre, n. 298. Accessed on 01.12.2019, at http://www.ces.es/TRESMED/docum/ita-cttn-ing.pdf. Krugman, Paul (2015), “The Austerity Delusion”, The Guardian. Accessed on 29.04.2015, at https://www.theguardian.com/business/ng-interactive/2015/apr/29/the-austerity-delusion. Landi, Stefano (2013), “Condizioni socio-economiche e tempi di attesa in Italia: analisi empirica basata sull’indagine ISTAT salute 2013”, in Giuseppe Costa; Roberta Crialesi; Alessandro Migliardi; Lidia Gargiulo; Gabriella Sebastiani; Paola Ruggeri; Francesca Menniti Ippolito (eds.), Salute in Italia e livelli di tutela: approfondimenti dalle indagini ISTAT sulla salute. Roma: Istituto Superiore di Sanità Editions. Accessed on 21.05.2019, at https://www.researchgate.net/profile/Stefano_Landi5/publication/317744696_CONDIZIO NI_SOCIO- ECONOMICHE_E_TEMPI_DI_ATTESA_IN_ITALIA_ANALISI_EMPIRICA_BASATA_SUL L'INDAGINE_ISTAT_SALUTE_2013/links/594b92e70f7e9ba3beb28a51/CONDIZIONI- SOCIO-ECONOMICHE-E-TEMPI-DI-ATTESA-IN-ITALIA-ANALISI-EMPIRICA-BASATA- SULLINDAGINE-ISTAT-SALUTE-2013.pdf.

191 Access to Care and the Global Financial Crisis in Italy: A Human Rights Perspective

Landman, Todd; Carvalho, Edzia (eds.) (2009), Measuring Human Rights. New York: Routledge [1st ed.]. La Repubblica (2013), “Legge di stabilità: tagli alla sanità per più di 4 miliardi in 3 anni”, October 14. Accessed on 07.01.2019, at http://www.repubblica.it/politica/2013/10/14/news/legge_di_stabilit_il_ministero_della_sal ute_con_i_nuovi_tagli_salta_il_sistema-68563840/. Mackenbach, Johan (2013), “The Unequal Health of Europeans: Success and Failure of Policies”, The Lancet, 381(9872), 1125-1134. McIsaac, Michelle; Kutzin, Joseph; Dale, Elina; Soucat, Agnès (2018), “Results-Based Financing in Health: From Evidence to Implementation”, Bulletin of the World Health Organization, 96(11), 730-730A. DOI: 10.2471/BLT.18.222968 McKee, Martin; Stuckler, David (2011), “The Assault on Universalism: How to Destroy the Welfare State”, BMJ, 343, d7973. MSF – Medici Senza Frontiere (2018), “Nuovo Rapporto ‘Fuori Campo’. Mappa di migranti e rifugiati esclusi dal sistema di accoglienza”, March 13. Accessed on 21.05.2019, at https://www.medicisenzafrontiere.it/news-e-storie/news/nuovo-rapporto-%C2%93fuori- campo%C2%94-mappa-di-migranti-e-rifugiati-esclusi-dal-sistema-di/. OECD – Organisation for Economic Co-operation and Development (2016), “Health Expenditure as a Share of GDP, selected European countries, 2005-15”. Accessed on 05.01.2019, at http://www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration- health/health-at-a-glance-europe-2016/health-expenditure-as-a-share-of-gdp-selected- european-countries-2005-15-graph_health_glance_eur-2016-graph101- en#.WoSBuajibIU. OECD – Organisation for Economic Co-operation and Development (2018a), “Health Care Resources: Hospitals”, OECD.Stat. Accessed on 23.05.2019, at https://stats.oecd.org/Index.aspx?DataSetCode=HEALTH_REAC#_ga=2.188533035.228 645678.1560190180-1842284939.1560190180. OECD – Organisation for Economic Co-operation and Development (2018b), “Health Care Resources: Hospital Beds”, OECD.Stat. Accessed on 23.05.2019, at https://stats.oecd.org/Index.aspx?DataSetCode=HEALTH_REAC#_ga=2.188533035.228 645678.1560190180-1842284939.1560190180. OECD – Organisation for Economic Co-operation and Development; European Observatory on Health Systems and Health Policies (2017), “Spain: Country Health Profile”, State of Health in the EU, 2017. Accessed on 23.05.2019, at: https://ec.europa.eu/health/sites/health/files/state/docs/chp_es_english.pdf. Ortiz, Isabel; Cummins, Matthew; Capaldo, Jeronim; Karunanethy, Kalaivani (2015), “The Decade of Adjustment: A Review of Austerity Trends 2010-2020 in 187 Countries”, Extension of Social Security (EES) Working Papers, 53. Geneva: ILO. Accessed on 02.01.2019, at http://www.ilo.org/wcmsp5/groups/public/---ed_protect/--- soc_sec/documents/publication/wcms_431730.pdf.

192 Rossella De Falco

Petrelli, Alessio; De Luca, Giuliana; Landriscina, Tania; Costa, Giuseppe (2012), “Socioeconomic Differences in Waiting Times for Elective Surgery: A Retrospective-Based Study”, BMC Health Services Research, 12, 268. Petrelli, Francesco (2013), “The True Cost of Austerity and Inequality – Italy Case Study”, Oxfam Case Study. Accessed on 01.01.2019, at https://www-cdn.oxfam.org/s3fs- public/file_attachments/cs-true-cost-austerity-inequality-italy-120913-en_0.pdf. Ramirez, Steven (2011), “Taking Economic Human Rights Seriously After the Debt Crisis”, Loyola University Chicago Law Journal, 42(4), 713-740. Rebba, Vincenzo (2009), “I ticket sanitari: strumenti di controllo della domanda o artefici di disuguaglianze nell’accesso alle cure?”, Politiche Sanitarie, 10, 221-242. DOI: 10.1706/473.5587 Salomon, Margot E. (2015), “Of Austerity, Human Rights and International Institutions”, LSE Legal Studies Working Paper, 2. Accessed on 03.01.2019, at https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2551428. Therborn, Goran (2012), “The Killing Fields of Inequality”, International Journal of Health Services, 42(4), 579-589. UIS – UNESCO Institute for Statistics (2012), “International Standard Classification of Education – ISCED 2011”. Accessed on 02.12.2019, at http://uis.unesco.org/sites/default/files/documents/international-standard-classification-of- education-isced-2011-en.pdf. United Nations (1967), “International Covenant on Economic, Social and Cultural Rights”, Treaty Series, vol. 993, p. 3, Article no. 12.2. Accessed on 02.01.2019, at https://treaties.un.org/doc/Treaties/1976/01/19760103%2009-57%20PM/Ch_IV_03.pdf. United Nations (2000), “General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant)”, E/C.12/2000/4. Geneva: Committee on Economic, Social and Cultural Rights. Accessed on 01.12.2019, at https://www.refworld.org/docid/4538838d0.html. United Nations (2015), “Concluding Observations on the Fifth Periodic Report of Italy”, E./C.12/ITA/CO/5. Geneva: Committee on Economic, Social and Cultural Rights. Werner, Richard (2014), “Enhanced Debt Management: Solving the eurozone crisis by Linking Debt Management with Fiscal and Monetary Policy”, Journal of International Money and Finance, 49, 443-469. WHO – World Health Organization (2000), “The World Health Report 2000 – Health Systems: Improving Performance”. Accessed on 20.01.2019, at http://www.who.int/whr/2000/en/whr00_en.pdf?ua=1.

193

@cetera

e-cadernos CES, 31, 2019: 195-211

TÂNIA REGINA KRÜGER

SISTEMA ÚNICO DE SAÚDE: REDUÇÃO DAS FUNÇÕES PÚBLICAS E AMPLIAÇÃO AO MERCADO*

Resumo: Este texto tem como objetivo problematizar as tensões na relação entre público e privado do Sistema Único de Saúde (SUS) brasileiro. As comemorações dos 30 anos do SUS aconteceram numa conjuntura política na qual o país se confronta com um retrocesso político-institucional sem precedentes e com um esfacelamento da garantia dos direitos de cidadania. Assumindo uma natureza exploratória, o texto foi desenvolvido com base numa revisão bibliográfica e documental e no marco normativo do SUS. Este estudo trata brevemente das contrarreformas que foram golpeando o SUS, desde a sua regulamentação e apresenta indicadores de como este vem se tornando funcional para o setor privado da saúde. Toda esta análise crítica não desconsidera que o SUS construiu serviços públicos relevantes e é uma das políticas sociais mais caras às lutas democrático- populares, podendo ser considerado, portanto, um patrimônio nacional. Palavras-chave: Brasil, política social, relação entre público e privado, Sistema Único de Saúde.

UNIFIED HEALTH SYSTEM: REDUCTION OF PUBLIC FUNCTIONS AND MARKET EXPANSION

Abstract: This text aims to discuss the tensions in the relationship between the public and the private sectors in the Brazilian Unified Health System (UHS). The celebrations of the 30th anniversary of the UHS took place in a political conjuncture in which the country was facing an unprecedented setback in the political and institutional process and a disintegration of the guarantee of citizenship rights. Assuming an exploratory nature, the study was based on a bibliographical and documentary review of UHS regulations. It deals with counter-reforms that have been striking the UHS since its inception and displays indicators of how it has become functional to the private health sector. All this critical analysis does not disregard the fact that the UHS has built relevant public services and that it is one of the most important achievements in social policies for democratic and popular struggles, and can therefore be considered a national heritage. Keywords: Brazil, relationship between public and private, social policy, Unified Health System.

* 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) do Departamento de Serviço Social da Universidade Federal de Santa Catarina (UFSC), no Brasil, e coordenado pela autora pesquisadora PQ2 do CNPq. O texto integra também o relatório de pesquisa 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.

195 Tânia Regina Krüger

INTRODUÇÃO O Sistema Único de Saúde (SUS), resultado do movimento da Reforma Sanitária no Brasil, institucionalizou-se como uma política pública estatal, universal, descentralizada, gratuita e com participação da comunidade. Os seus fundamentos expressam as contradições da sociedade e o caráter liberal, democrático e universalista desta, ao combinar políticas estatais universais, contributivas e focalizadas em políticas de mercado. Com 30 anos completos em 2018, o SUS encontra-se em franco processo de dilapidação e desconstitucionalização. Esse brutal desmonte do SUS teve início em 2016 e o colocou numa encruzilhada que parece ultrapassar as contrarreformas que vivenciou desde 1990. O desmonte dos princípios doutrinários (o sentido de público, coletivo, universal, integral e participativo) e dos princípios organizativos (base orçamentária, contratação de trabalhadores, resolutividade dos serviços, forma de gestão, etc.) vem acontecendo de forma agressiva, ainda que esses princípios permaneçam na forma da lei (Brasil, 1990a). Assim, nessa conjuntura, o presente texto tem como objetivo problematizar a relação entre público e privado no SUS, considerando a sua tensa trajetória de institucionalização e implementação. A desconstitucionalização do SUS, aqui também chamada de contrarreforma, está avançando num contexto de desmonte e privatização de empresas e dos serviços públicos estatais. E aí se colocam os desafios para identificar e 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 está desmontando o sentido de direito público e coletivo pela necessidade de acesso desse setor ao fundo público. Tal retrocesso é resultado de um esfacelamento da garantia dos direitos de cidadania como 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 (Banco Mundial, 2017) e ainda como O caminho da prosperidade – Proposta de plano de governo: constitucional, eficiente e fraterno (Bolsonaro, 2018). Ou seja, é uma conjuntura de desconstitucionalização que envolve diretamente emendas constitucionais, legislação infraconstitucional nas esferas nacional e subnacionais, redução do financiamento e sucateamento dos serviços públicos. Todo este processo está permeado por uma crise ideológica e política que está destruindo, com o apoio dos meios de comunicação, as bases relativamente progressistas do Estado democrático, timidamente construídas. Tendo uma natureza exploratória, o texto foi desenvolvido com base numa revisão bibliográfica e documental e no marco normativo do SUS, bem como na sistematização

196 Sistema Único de Saúde: redução das funções públicas e ampliação para o mercado de experiências oriundas de diferentes vivências políticas e acadêmico-profissionais do trabalho na saúde. O texto foi estruturado em duas partes: a primeira, sobre a trajetória de implementação do SUS e suas contrarreformas; a segunda sobre a redução do SUS como serviço público e a sua ampliação para os serviços privados de saúde. Toda esta análise crítica não desconsidera que o SUS é uma das políticas sociais mais caras às lutas democrático-populares brasileiras, podendo, portanto, ser considerado um patrimônio nacional.

1. SUS: CONFLITOS ENTRE OS FUNDAMENTOS DEMOCRÁTICOS E AS CONTRARREFORMAS Segundo os fundamentos do SUS, a saúde não é o resultado de um procedimento biológico-curativo a ser tratado pelos serviços médicos e medicamentos (Paim, 2011), mas sim resultado de determinações socioeconômicas que devem ter uma resposta no espaço público, mediada pela participação dos sujeitos sociais num contexto de Estado democrático. A partir de 1990, o Estado brasileiro foi adequando a sua gestão às políticas neoliberais e se organizando como um Estado liberal-social. O governo de Fernando Henrique Cardoso caracterizou-se pela implementação de políticas estatais e privatistas. Este governo questionou as aspirações democráticas da década de 1980 e da Constituição de 1988 e colocou-as como empecilho à governabilidade e à modernização; por isso organizou políticas para a flexibilização do mundo do trabalho e subsidiou as privatizações com fundos públicos por intermédio do sistema bancário.1 Nessa década, o Movimento da Reforma Sanitária, por ter centrado as suas forças na conquista do arcabouço legal, ficou em posição defensiva, por vezes resistindo aos ataques ao SUS e por vezes assumindo, através de seus membros, cargos em governos de caráter progressista nas instâncias subnacionais. Evidenciou-se na época a fragilidade político-organizacional dos espaços institucionalizados de participação – Conselho e Conferências –,2 apesar de resistências locais para enfrentar o desfinanciamento, a desconcentração de serviços e a recentralização das decisões e dos recursos. A reafirmação do SUS como política pública universal de caráter coletivo e obrigação do Estado, na maioria das vezes nos espaços dos Conselhos e Conferências, assim como nos movimentos sociais, na academia e na organização dos gestores, cedeu lugar a reivindicações mais imediatistas para que se cumprisse a lei,

1 O Banco Nacional de Desenvolvimento Econômico e Social (BNDES), 100% estatal, vem sendo o principal gestor das privatizações federais e assessor das privatizações estaduais brasileiras. Como o mercado de capitais não tem financiado as privatizações o BNDES, faz empréstimos diretos aos compradores (C. Santos, 1997). 2 A Constituição de 1988, artigo 198, indica que uma das diretrizes do SUS é a participação da Comunidade. A Lei 8.142/1990 regulamentou determinou que a participação da comunidade se dará desse em dois espaços colegiados, o Conselho e as Conferências (Brasil, 1990a, 1990b).

197 Tânia Regina Krüger organizasse a rede de serviços, se realizassem concursos públicos e se prestassem os serviços (Bravo e Menezes, 2010). Em 2002, a vitória de Lula, do Partido dos Trabalhadores (PT), nas eleições presidenciais, teve um significado real e simbólico para um país dotado de enorme conservadorismo e desigualdades. Foi uma vitória tardia, pois para poder vencer e governar, o PT fez concessões, abandonou bandeiras que o caracterizaram desde 1979 e aliou-se a grupos políticos de centro-direita vinculados ao capital industrial, buscando os riscos do apoio de uma base pluriclassista, mas sempre disposto à mediação entre as ações que buscavam a elevação dos padrões de vida dos mais pobres e as que propiciaram ganhos à elite (Antunes, 2004; Belluzzo, 2013). Na saúde, como nas demais políticas sociais, os governos do Partido dos Trabalhadores propiciaram certa reanimação das forças progressistas, destacando-se o retorno à concepção de Reforma Sanitária; a escolha de profissionais comprometidos com a Reforma Sanitária para ocuparem cargos de responsabilidade no Ministério da Saúde; a convocação das Conferências Nacionais de Saúde com regularidade; a aprovação da Política de Atenção Básica e do Pacto Pela Saúde em 2006 para retomar alguns princípios do SUS; a ênfase na Estratégia de Saúde da Família como política estruturante e porta de entrada preferencial no SUS; o incentivo à formação de profissionais de saúde com perfil para trabalhar no SUS; a aprovação da Política Nacional de Medicamentos e da Saúde Bucal entre outros (Bravo e Menezes, 2010). Ao mesmo tempo evidenciaram-se fragilidades na implementação do SUS, como por exemplo uma concepção de Seguridade Social desarticulada da Previdência e Assistência Social; a não aprovação do Plano Único de Cargos, Carreira e Salários (PCCS); o silêncio do Ministério da Saúde perante a multiplicação de serviços entregues às organizações sociais, nas esferas subnacionais do SUS, e perante as inúmeras denúncias quanto à qualidade desses serviços; e, também, a omissão do Ministério perante a desvinculação formal dos hospitais das universidades, quando em 2011 foi criada a Empresa Brasileira de Serviço Hospitalares – EBSERH, uma empresa pública de direito privado destinada a gerir os 37 hospitais Universitários públicos-federais (Brasil, 2011a). Com a assunção ilegítima a Presidência da República, por Michel Temer em 2016, o Estado brasileiro vem adotando políticas radicais de austeridade fiscal, num processo contínuo de redução dos direitos sociais e de mercantilização da gestão e prestação dos serviços sociais, bem como de redução do financiamento da seguridade social. Com a sua agenda conservadora, o governo Temer não só acirrou o fortalecimento do setor privado em detrimento do SUS, como oportunizou as maiores manifestações do populismo de direita. Nesse governo, a aplicação da política de austeridade adquiriu

198 Sistema Único de Saúde: redução das funções públicas e ampliação para o mercado contornos dramáticos, deixando o SUS com uma “atuação subordinada e subalterna, como recurso complementar ao mercado” (Miranda, 2017: 399). Destacamos aqui algumas medidas recentes que expressam este desmonte do SUS: a) a aprovação da Emenda Constitucional (EC 95), que limita o crescimento das despesas primárias à taxa de inflação, durante um período de 20 anos; b) a revisão das diretrizes da Atenção Básica (Brasil, 2017b), num sentido oposto à perspectiva integradora da Atenção Primária à Saúde (APS); c) a significativa redução do Programa Farmácia Popular; d) a alteração das diretrizes da Política Nacional de Saúde Mental (PNSM), o que significa um retrocesso da Reforma Psiquiátrica Brasileira e que pode ter como consequência a desassistência e retorna da institucionalização; e) a limitação do credenciamento das Instituições de Educação Superior exclusivamente à oferta de cursos de graduação na modalidade à distância, sem prever um tratamento diferenciado para a área da saúde (Brasil, 2017a); f) a decisão da Agência Nacional de Vigilância Sanitária (Anvisa) relativamente a liberar o uso de Benzoato de Emamectina, um agrotóxico agressivo, que havia sido proibido em 2010 por elevada neurotoxicidade e suspeita de causar malformações; g) a redução dos blocos ou áreas de financiamento do SUS de seis3 para dois: um de custeio, que concentra a quase totalidade dos recursos federais, e outro de investimento. Em nome da flexibilização, esta política fragmenta e desfigura o sistema de financiamento definido pelo Pacto pela Saúde (Brasil, 2007), comprometendo nas esferas infranacionais a manutenção e a ampliação dos serviços e dando mais liberdade à gestão para atender as conveniências políticas locais (Brasil, 2017c). Em fins de 2018 a eleição de Jair Bolsonaro para presidente representou no país uma escancarada viragem à direita e uma divisão profunda da sociedade. Vive-se uma onda reacionária diferente das outras, que tenta acabar com a distinção entre ditadura e democracia. A opinião pública está sendo destruída com notícias falsas que transformam o adversário em inimigo (B. S. Santos, 2018). Para se eleger, o novo presidente apresentou-se como candidato antissistema, encarnou a rejeição e as insatisfações populares com um discurso violento, baseado no senso comum. As suas declarações antidemocráticas receberam da população apoio acrítico incondicional.

3 Os blocos de financiamento do Pacto pela Saúde eram: Atenção Básica, Atenção de Média e Alta Complexidade Ambulatorial e Hospitalar, Vigilância em Saúde, Assistência Farmacêutica, Gestão do SUS e Investimentos na Rede de Serviços de Saúde (Brasil, 2007).

199 Tânia Regina Krüger Este governo, segundo Martins (2018), inicia-se com uma aliança entre a burguesia emergente, centrada no empresariado neopentecostal, o agronegócio, o rentismo, a oficialidade militar, o grande capital estrangeiro e o imperialismo estadunidense antiliberal. Mesmo antes de iniciar o governo, o SUS teve uma das suas maiores perdas, pois o Governo cubano decidiu retirar do país os profissionais que pertenciam ao Programa Mais Médicos,4 em função das “declarações ameaçadoras e depreciativas” do presidente eleito para com aquele governo. A saída de aproximadamente 8500 médicos do país afetou 28 milhões de pessoas em 1575 municípios brasileiros (Matoso, 2018; Conselho Nacional de Saúde, 2018). O ministro da saúde do novo governo, Luiz Henrique Mandetta, em seu discurso de posse, referenciou o SUS como uma continuidade de saberes, ao mesmo tempo que prometeu cumprir o desafio constitucional de a saúde ser um direito de todos e um dever do Estado. Mas essa promessa não combina com a ênfase que ele colocou no grande compromisso com a família, com a fé, com o país e com a pátria, revelando a sua histórica relação com o setor filantrópico e com empresas e políticos vinculados ao setor privado da saúde (Brasil, 2019b). Ao longo dos seus 30 anos, o SUS foi marcado por momentos de valorização e por momentos de desvalorização dos seus fundamentos, ou seja, o Estado democrático, a igualdade, a democracia e a saúde como direito coletivo e obrigação do Estado. No sentido da valorização, o SUS ganhou sustentabilidade institucional, por meio de uma rede de instituições de ensino e pesquisa nas universidades, nos institutos e nas escolas de saúde pública, nos colegiados de participação e controle social e por meio de uma rede de entidades e movimentos sociais que o defendem. Igualmente ganhou materialidade que se expressa em estabelecimentos, trabalhadores, equipamentos, tecnologias, sistemas de informação, serviços amplamente reconhecidos, indicadores de 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, o qual se deve a diversas medidas e políticas, de entre as quais se destacam: o combate à pobreza, o programa farmácia popular, o serviço de urgência (Serviço de Atendimento Móvel de Urgência – SAMU), o programa de saúde bucal, a inclusão social (políticas de saúde para as populações indígenas, quilombolas, ribeirinhas, em situação de rua e

4 O Programa Mais Médicos (PMM) foi criado em 2013 pelo Governo Federal para a melhoria do SUS, levando mais médicos para regiões onde há escassez ou ausência desses profissionais. O programa previu mais investimentos para construção, reforma e ampliação de Unidades Básicas de Saúde (UBS), além de novas vagas de graduação e residência médica para qualificar a formação dos seus profissionais (Brasil, 2019a). 5 A informação sobre os números e as realizações do SUS pode ser colhida nos Planos Nacionais de Saúde quadrienais (2004-2007; 2008-2011; 2012-2015; 2016-2019).

200 Sistema Único de Saúde: redução das funções públicas e ampliação para o mercado LGBT), o Programa Mais Médicos, a criação e ampliação de unidades e equipes da Estratégia Saúde da Família e as Unidades de Pronto Atendimento (UPA) (Brasil, 2011b, 2016). No sentido inverso, estas três décadas foram também marcadas por ações políticas regressivas, sendo imperioso reconhecer a existência de obrigações legais que não foram cumpridas, designadamente as relacionadas com o princípio da universalidade e o financiamento público. 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 à pressão da agenda neoliberal. Segundo Paim:

esse aspecto negativo é agravado pelas limitadas bases sociais e políticas do SUS que não conta com a força de partidos, nem com o apoio de trabalhadores organizados em sindicatos e centrais para a defesa do direito à saúde inerente à condição de cidadania […]. O SUS sofre resistências de profissionais de saúde, cujos interesses não foram contemplados pelas políticas de gestão do trabalho e educação em saúde. Além da crítica sistemática e oposição da mídia, o SUS enfrenta grandes interesses econômicos e financeiros ligados a operadoras de planos de saúde, a empresas de publicidade e a indústrias farmacêuticas e de equipamentos médico-hospitalares. (2018: 1725)

A permanente indefinição quanto ao seu financiamento conduziu o SUS a uma enorme instabilidade e a uma situação de subfinanciamento crônico. A insuficiência dos recursos do SUS reflete-se negativamente na rede de infraestruturas públicas, na remuneração dos seus trabalhadores e nas respostas à população, obrigando-o a comprar serviços ao setor privado. Para Paim (ibidem), essa indefinição leva a um duplo boicote ao SUS: “um boicote passivo através do subfinanciamento público e ganha força um boicote ativo”, quando o Estado reconhece e privilegia o setor privado com subsídios, empréstimos, desonerações e contratualizações. Este favorecimento do SUS ao 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 da aplicação de subsídios aos estratos superiores de renda, ele acaba por promover o mercado de planos de saúde privados.

201 Tânia Regina Krüger Também o modelo tecnoassistencial e gerencial6 não sofreu descontinuidade. Persiste a perspectiva de uma administração pública gerencial que se pauta pela proposta de esvaziamento do papel do Estado de regulador das relações e de prestador de serviços públicos, ficando as suas atividades vinculadas às demandas do mercado. Para Marco Aurélio Nogueira, este clima ideológico solidificou-se quando as forças neoliberais vieram “a público proclamar que o Estado simbolizava o atraso indesejável e a constituição da modernidade, por todos almejada, dependia da negação do Estado” (Nogueira, 1998: 124). Deste modo, o entendimento sobre administração pública gerencial dominante, que coloca o Estado como gestor ineficiente e apresenta a gestão gerencial como sinônimo de eficiência, está de acordo com o segmento político e econômico que o defende e com o seu projeto político-econômico. Segundo Souza Filho (2006: 323), a hegemonia ideológica do projeto gerencialista ataca a finalidade de universalização de direitos, a dimensão racional e impessoal da ordem administrativa burocrática e promove a privatização de empresas e dos serviços públicos estatais. São inúmeras as situações que vêm descaracterizando e desconstitucionalizando o SUS que já não cabem nos limites desse texto. Mas é certo que no SUS, como em grande parte do território nacional, há um imenso descuido com a ambiência, com a eficiência da 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 nacional do SUS. O SUS vem se transformando, gradualmente, em mais um espaço dominado pela velha e tradicional promiscuidade da política brasileira, confirmando um padrão de descaso e de desrespeito em relação à dignidade humana e ao uso da riqueza socialmente produzida.7

6 O projeto gerencialista no âmbito de um projeto político-econômico conservador avança de maneira 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 público para fazer a gestão dos serviços SUS. Com essa política, os usuários dos serviços passam progressivamente a ser vistos como consumidores e clientes ao invés de cidadãos, ficando o Estado a atender os comprovadamente mais pobres (Souza Filho, 2006). Sob o pretexto de maior eficiência, exemplificamos, o Estado brasileiro repassa recursos aos empresários através de inúmeras figuras jurídicas, como as organizações sociais (OS), as Parcerias Público-Privadas (PPP), as Fundações Estatais de Direito Privado e Empresas Públicas (como a Empresa Brasileira de Serviços Hospitalares – EBSERH). 7 Mais um exemplo do descaso com proteção social da população brasileira pode ser exemplificado no Decreto presidencial n.º 9.699, de 8 de fevereiro de 2019. Transfere dotações orçamentárias constantes dos Orçamentos Fiscal e da Seguridade Social da União para diversos órgãos do Poder Executivo Federal, para encargos financeiros da União e para transferências a Estados, Distrito Federal e Municípios, no valor de R$ 606 056 926 691,00.

202 Sistema Único de Saúde: redução das funções públicas e ampliação para o mercado

2. SUS: FUNCIONAL AO SETOR PRIVADO E REDUZIDO NAS SUAS FUNÇÕES PÚBLICAS E

COLETIVAS Os 30 anos do SUS também foram marcados por uma queda do seu peso na despesa pública, entre 2010 e 2015, enquanto a saúde privada passou a representar uma fatia maior do que em países ricos.8 A história do SUS pautou-se por uma contradição fundamental que consiste na segmentação dos serviços devido ao uso da dupla cobertura pelo sistema público e pelo setor privado. A defesa dos fundamentos da Reforma Sanitária e do SUS sempre foram tensionados pela corrente antissanitarista, que defende o Estado mínimo, o paradigma privatista, 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 ao setor privado da saúde (hospitais, clínicas, indústria de medicamentos e equipamentos) (Bahia, 2018). O setor privado da saúde defende que o sistema público é para atender os pobres, as regiões distantes do país, os serviços de vigilância à saúde, atender as calamidades e garantir os serviços de alto custo, pois nesses serviços o próprio setor privado é usuário. Este segmento, segundo Ronaldo dos Santos (2018a), estrutura-se a partir de uma racionalidade privada mercantil e vem operando uma inversão de valores, convertendo a universalidade e a gratuidade dos serviços em resíduos históricos regressivos e em privilégios, e defende as parcerias privadas como arranjos superiores à administração direta estatal. 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, o deslocamento da base social de apoio ao SUS e promove a cultura corporativa de direitos presente nas relações de trabalho. Conforme Ronaldo dos Santos (2018a), os planos coletivos privados representam 76% desse mercado e se relacionam essencialmente com as demandas sindicais.9 Essa cultura corporativa de direitos nas relações de trabalho é uma das causas do aumento das desigualdades em saúde, da não universalização dos serviços e impõe sérios limites à construção de uma base social de apoio ao SUS. Para Ronaldo dos Santos (2018a), este tipo de prática do mundo do

8 Os dados da pesquisa Conta-Satélite de Saúde Brasil 2010-2015, do Instituto Brasileiro de Geografia e Estatística (IBGE), evidenciam que os gastos privados somaram 57,6% do total dos gastos 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-se pela persistência do “não diálogo”. Com a implementação do SUS, a assistência à saúde para parte da classe trabalhadora sindicalizada transitou gradativamente do modelo corporativo público estatal para uma dimensão corporativa mercantil. Os estudos do autor apontam que as demandas por planos de saúde privados tem sido uma pauta privilegiada nos acordos e convenções coletivas de trabalho e, contraditoriamente, o tema não ganhou centralidade nos debates dos sanitaristas defensores do SUS.

203 Tânia Regina Krüger trabalho ainda alimenta a racionalidade econômico-corporativa, o desconhecimento da magnitude dos serviços que o SUS realiza na atenção aos acidentes de trabalho e a baixa integração dos Centros de Referência em Saúde do Trabalhador (CEREST) – nos serviços de atenção básica, média e alta complexidade.10 A arrecadação do governo federal é reduzida, pois a pessoa física ou jurídica pode abater do imposto a pagar os gastos comprovados com planos e serviços particulares de saúde. Outra contradição no plano institucional do SUS é que os funcionários dos poderes executivo, legislativo e judiciário – isto é, o núcleo do poder decisório do Estado brasileiro – são cobertos por planos privados de saúde parcialmente financiados pelos empregadores públicos, e contam com benefícios da renúncia fiscal. Tal benefício significa a isenção do pagamento de tributos, especialmente no Imposto de Renda, por parte da pessoa física ou jurídica que contrata o plano privado de saúde. Essa política de renúncia da arrecadação fiscal provoca uma subtração de recursos ao SUS que correspondeu a um terço das despesas com Ações e Serviços Públicos de Saúde do Ministério da Saúde, entre 2003 e 2015 (Ocké-Reis, 2018). A isenção fiscal concedida aos planos de saúde por parte da União possibilita parte dos altos investimentos privados da saúde. “Esses subsídios equivaleram a 30% dos gastos federais com saúde em 2016” (Sobrinho, 2018). Tais iniciativas espelham a tendência de fortalecimento do setor privado em saúde, mas, contraditoriamente, o mercado requer um SUS que lhe seja funcional, nos termos de Paim:

este SUS que está aí ainda é muito orgânico aos interesses privados. Além de comprar medicamentos e equipamentos, atender às empreiteiras para construir UPAs e hospitais, o SUS funciona como um resseguro para essas empresas de planos de saúde. Quando o risco sobe, elas jogam o cliente para o público. Então, a princípio, não é interessante para eles que o SUS acabe. (apud Mathias, 2018)

Para além do problema histórico do subfinanciamento, novas estratégias do capital para a saúde corroem os pilares de um sistema público e universal, pressupondo a responsabilidade dos indivíduos e a ajuda do Estado, desaparecendo a figura jurídica

10 O CEREST é um local de atendimento SUS especializado em Saúde do Trabalhador, o qual recebe usuários encaminhados pela a rede básica; o trabalhador formal dos setores privado e público; o trabalhador autônomo; o trabalhador informal; e o trabalhador desempregado acometido de doença relacionada com o trabalho realizado. O CEREST presta assistência especializada aos trabalhadores acometidos por doenças e/ou acidentes relacionados com o trabalho; realiza promoção, proteção, recuperação da saúde; investiga as condições do ambiente de trabalho utilizando dados epidemiológicos e é uma fonte geradora de conhecimento para indicar se as doenças estão relacionadas com as atividades que elas exercem (Brasil, 2015b).

204 Sistema Único de Saúde: redução das funções públicas e ampliação para o mercado do direito à saúde. Para exemplificar, a tramitação no Brasil da criação dos Planos de Saúde Acessíveis (populares) se assenta nas seguintes premissas: segmentação das coberturas assistenciais, redução da lista dos procedimentos com cobertura obrigatória, redução do valor que as operadoras devem restituir ao SUS e reajustes regulares da mensalidade de pessoas com mais de 60 anos de idade, regulados pela Lei n.º 9.656 de 1998 (ABRASCO, CEBES e IDEC, 2017; Brasil, 1998). O processo de desconstitucionalização do SUS pode ainda ser ilustrado com inúmeras alterações legislativas, tais como a Lei n.º 13.097/2015, que estabelece a permissão do investimento de capital estrangeiro nos serviços de saúde e da contratualização como serviço complementar ou como gestor do SUS (Brasil, 2015a). Na análise de Mendes e Funcia (2016: 159) “essa Lei veio para dificultar ainda mais a possibilidade de ampliarmos o direito à saúde e assegurar a insaciabilidade do capital na forma de apropriação do fundo público”. As contradições fundamentais e os dados oficiais sobre SUS permitem-nos afirmar com certa facilidade que o SUS nunca foi universal. As proporções relativas da despesa pública (42%) e privada (58%), que pouco oscilaram nas últimas três décadas (Bahia, 2018), ajudam a sustentar a evidência da não universalização. Mas a estes gastos privados estão vinculados cerca de 50 milhões de pessoas, ou seja, a 25% da população brasileira, que também utiliza o SUS. “O setor público predomina na produção total de atividades (65%), mas recebeu apenas 10% dos valores de remuneração, ao passo que o privado e o filantrópico, responsáveis por 35% dos atendimentos, 90%” (ibidem). Não existindo solução única, muito menos de corte tecnocrático, para universalização do SUS, um dos caminhos é aumentar a despesa pública em saúde. A despesa total em saúde, no Brasil, atingiu 8,3% do Produto Interno Bruto (PIB) em 2014, 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 países com forte investimento público despendem mais de 70% da despesa total em saúde (Jornal Económico, 2017; Reis et al., 2016). Evidências internacionais sugerem que a universalização dos sistemas de saúde implica gastos públicos iguais ou superiores a 70% dos gastos totais em saúde, situando-se o Brasil mais de 20 pontos percentuais abaixo desse patamar. Esta funcionalidade do SUS no setor privado é evidenciada em manifestações do setor privado 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 (Associação Nacional de Administradoras de Benefícios). Na avaliação dos especialistas que

205 Tânia Regina Krüger participaram desse Fórum, o SUS, que faz 30 anos, é referência em saúde pública, porém tem o desafio de melhorar o atendimento no tratamento de média complexidade, justamente no serviço que é mais lucrativo para o setor privado (Lott, 2018). Na avaliação de Paim (2018), “a luta pela privatização está saindo do armário e chegando ao DNA do nosso arcabouço legal que é a Constituição de 1988. É um ataque ao pacto que foi construído depois da ditadura”. Neste contexto e a partir de 2016 apareceram no cenário nacional várias entidades a propor uma segunda alma para o SUS, ou a sua refundação numa base de complementaridade entre público e privado. É o caso da Associação Nacional dos Hospitais Privados (Anahp), a Coalizão Saúde, a Federação Brasileira de Planos de Saúde (FEBRAPLAN) e o Colégio Brasileiro de Executivos da Saúde (CBEXs), que convergem na defesa da integração total entre o SUS e o setor privado (Mathias, 2016). Por esta via, a esfera pública está sendo colocada a serviço do mercado e alijada da sua estrutura 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 os movimentos sociais e entidades que historicamente lutaram para a construção e a defesa do SUS constitucional, como o Centro Brasileiro de Estudos de Saúde (CEBES), a Associação Brasileira de Saúde Coletiva (ABRASCO), o Instituto de Direito Sanitário (IDISA) e a Frente Nacional Contra a Privatização da Saúde, entre outros segmentos sociais progressistas. A estratificação complexa do SUS e a relação complementar com o setor privado marcaram os serviços que foram ou se aproximaram da universalidade: vigilância sanitária e epidemiológica, vacinações, zoonoses, vigilância da água, atenção básica, medicamentos para tuberculose, hanseníase, HIV/AIDS, hipertensão, diabetes, serviços de alto custo e alta complexidade como a nefrologia e transplantes. O impacto dessas políticas de saúde foi reconhecido nacional e internacionalmente. A revista British Medical Journal, por exemplo, destacou os progressos associados aos vários programas sociais e de saúde que levaram a “um dos declínios mais rápidos na mortalidade abaixo de 5 anos já registado” (Hennigan, 2010: 1190).

CONSIDERAÇÕES FINAIS Nos 30 anos do SUS prevaleceu uma acepção positiva sobre a natureza democrática do projeto, mas a democratização dos cuidados de saúde permaneceu pendente de realização. Nessa implementação, o bloco político institucional e organizativo que

11 Entendemos por fundamentos do SUS: a saúde como direito universal, o conceito ampliado de saúde, os seus objetivos, competências e princípios (artigos 5.º ao 7.º da lei n.º 8.080/1990), a determinação social da saúde e a gestão pública estatal com base no direito público.

206 Sistema Único de Saúde: redução das funções públicas e ampliação para o mercado formulou o SUS perdeu a sua capacidade de resistência e defesa dos princípios do sistema público de saúde. Assim, as agendas políticas dos governos dessas três décadas foram conformando novas tendências em relação à direção ideo-política do SUS. A perspectiva privatista alargou a relação com setor privado renovando as formas de contratos, subsídios e empréstimos suportados pelo fundo público. As associações e os grupos de representantes do setor privado, que raramente se manifestavam publicamente, 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 o privado. A defesa do SUS constitucional reside no segmento que defende as bandeiras do Movimento da Reforma Sanitária, mas que é hoje claramente contra-hegemônico. Sabemos das contradições e divergências que acercam o debate da defesa do SUS no conjunto de entidades e movimentos sociais, mas torna-se necessária a articulação em torno da construção de uma política unitária e da revitalização das bandeiras de lutas em defesa dos direitos sociais, trabalhistas e previdenciários, de modo a alterar a presente correlação de forças que pende para o mais sombrio da humanidade. O projeto brasileiro da Reforma Sanitária necessita dos rituais democráticos para seguir o processo de implementação do SUS de acordo com seus fundamentos. Os opositores de um sistema público de saúde sobreviveram à redemocratização, ao Movimento da Reforma Sanitária e ampliaram a sua ação nos 30 anos do SUS. Assim, a bandeira de gestão pública estatal, dos serviços públicos e do investimento no setor público não podem ser reivindicação menor do segmento que defende o SUS.

Revisto por Rita Cabral

TÂNIA REGINA KRÜGER Universidade Federal de Santa Catarina Rua Eng.º Agronômico Andrei Cristian Ferreira, s/n, Trindade, 88040-900 Florianópolis, Santa Catarina, Brasil Contacto: [email protected]

REFERÊNCIAS BIBLIOGRÁFICAS ABRASCO; CEBES; IDEC (2017), “Informe Abrasco, Cebes e Idec sobre possíveis alterações na Lei dos Planos de Saúde”, ABRASCO, 29 de setembro. Consultado a 10.02.2019, em https://www.abrasco.org.br/site/outras-noticias/institucional/informe-abrasco-cebes-e- idec-sobre-possiveis-alteracoes-na-lei-dos-planos-de-saude/31004/. Antunes, Ricardo (2004), A desertificação neoliberal no Brasil. Campinas: Autores Associados.

207 Tânia Regina Krüger

Bahia, Ligia (2018), “Trinta anos de Sistema Único de Saúde (SUS): uma transição necessária, mas insuficiente”, Cadernos de Saúde Pública, 34(7). Consultado a 01.08.2018, em http://cadernos.ensp.fiocruz.br/csp/artigo/505/trinta-anos-de-sistema-nico-de-sade-sus- uma-transio-necessria-mas-insuficiente 1/8. DOI: 10.1590/0102-311X00067218 Banco Mundial (2017), “Um ajuste justo - Análise da eficiência e equidade do gasto público no Brasil”, 21 de novembro. Consultado a 05.02.2018, em http://www.worldbank.org/pt/country/brazil/publication/brazil-expenditure-review-report. Belluzzo, Luiz Gonzaga (2013), “Os anos do povo”, in Emir Sader (org.), 10 anos de governos pós-neoliberais no Brasil – Lula e Dilma. Rio de Janeiro: Boitempo Editorial/FLACSO Brasil, 103-110. Bocchini, Bruno (2018), “Pesquisa mostra que quase 70% dos brasileiros não têm plano de saúde particular”, 21 de fevereiro. Consultado a 13.02.2019, em http://agenciabrasil.ebc.com.br/geral/noticia/2018-02/pesquisa-mostra-que-quase-70- dos-brasileiros-nao-tem-plano-de-saude-particular. Bolsonaro, Jair (2018), “O caminho da prosperidade. Proposta de Plano de Governo: constitucional, eficiente, fraterno”. Consultado em 10.12.2018, em https://static.cdn.pleno.news/2018/08/Jair-Bolsonaro-proposta_PSC.pdf. Brasil (1990a), Lei n.º 8.080 de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Brasil (1990b), Lei n.º 8.142, de 28 de dezembro de 1990. Dispõe sobre a participação da comunidade na gestão do Sistema Único de Saúde (SUS). Brasil (1998), Lei n.º 9.656 de 3 de junho de 1998. Dispõe sobre os planos e seguros privados de assistência à saúde. Consultado a 25.11.2019, em http://www.planalto.gov.br/ccivil_03/leis/l9656.htm. Brasil (2007), Portaria n.º 204, de 29 de janeiro de 2007. Regulamenta o financiamento e a transferência dos recursos federais para as ações e os serviços de saúde, na forma de blocos de financiamento, com o respectivo monitoramento e controle. Brasil (2011a), Lei n.º 12.550, de 15 de dezembro de 2011. Autoriza o Poder Executivo a criar a empresa pública denominada Empresa Brasileira de Serviços Hospitalares – EBSERH; acrescenta dispositivos ao Decreto-Lei nº 2.848, de 7 de dezembro de 1940 – Código Penal; e dá outras providências. Consultado a 10.02.2019, em http://www.planalto.gov.br/ccivil_03/_Ato2011-2014/2011/Lei/L12550.htm. Brasil (2011b), “Plano Nacional de Saúde (PNS) de 2012 a 2015”. Brasília: Ministério da Saúde. Brasil (2015a), Lei n.º 13.097, de 19 de janeiro de 2015, Seção 1, p. 1. Brasília: DOU. Consultado a 05.10.2017, em http://www.planalto.gov.br/ccivil_03/_ato2015- 2018/2015/lei/l13097.htm. Brasil (2015b), “Centro de Referência em Saúde do Trabalhador – CEREST”, 20 de maio. Consultado a 12.02.2019, em http://bvsms.saude.gov.br/dicas-em-saude/1086-centro-de- referencia-em-saude-do-trabalhador-cerest.

208 Sistema Único de Saúde: redução das funções públicas e ampliação para o mercado

Brasil (2016), Plano Nacional de Saúde de 2016 a 2019. Brasília: Ministério da Saúde. Brasil (2017a), Decreto n.º 9.057, de 25 de maio. Consultado a 12.02.2019, em http://www.planalto.gov.br/ccivil_03/_Ato2015-2018/2017/Decreto/D9057.htm. Brasil (2017b), Portaria n.º 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Brasília: Ministério da Saúde. Brasil (2017c), Portaria n.º 3.992/2017 de 28 de dezembro. Consultado a 14.02.2019, em http://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt3992_28_12_2017.html. Brasil (2019a), “Mais Médicos para o Brasil, mais saúde para você”. Consultado a 14.02.2019, em http://maismedicos.gov.br/conheca-programa. Brasil (2019b), “Discurso de posse do ministro da Saúde, Luiz Henrique Mandetta”, Blog da Saúde, 15 de janeiro. Consultado a 16.01.2019, em http://www.blog.saude.gov.br/index.php/geral/53718-discurso-do-ministro-da-saude-luiz- henrique-mandetta-transmissao-de-cargo. Bravo, Maria Inês; Menezes, Juliana (2010), “A política de saúde no governo Lula: algumas reflexões”, in Maria Inês Bravo; Valério D’Acri; Janaina Bilate Martins (orgs.), Movimentos sociais, saúde e trabalho. Rio de Janeiro: ENSP/Fiocruz, 45-69. Figueiredo, Juliana Oliveira; Prado, Nilia Mara de Brito Lima; Medina, Maria Guadalupe; Paim, Jairnilson Silva (2018), “Gastos público e privado com saúde no Brasil e países selecionados”, Saúde Debate, 42(número especial 2), 37-47. Consultado a 25.11.2019, em https://www.scielosp.org/pdf/sdeb/2018.v42nspe2/37-47/pt. Conselho Nacional de Saúde (2018), “Médicos da atenção básica migram para mais médicos, gerando risco de desfalque no SUS”, SUSCONECTA, 12 de dezembro. Consultado a 19.12.2018, em http://www.susconecta.org.br/medicos-da-atencao-basica-migram-para- mais-medicos-gerando-risco-de-desfalque-no-sus/. Hennigan, Tom (2010), “A Revolution in Primary Healthcare”, British Medical Journal, 341(7784), 1190-1191. Jornal Económico (2017), “Sabe como são as despesas de saúde nos vários países do mundo?”, 7 de abril. Consultado a 17.08.2018, em https://jornaleconomico.sapo.pt/noticias/sabe- como-sao-as-despesas-de-saude-nos-varios-paises-do-mundo-143185. Lott, Diana (2018), “Apesar de problemas, SUS é referência em saúde pública, dizem especialistas”, Folha de São Paulo, 23 de abril. Consultado a 29.04.2018, em https://www1.folha.uol.com.br/seminariosfolha/2018/04/apesar-de-problemas-sus-e-referencia- em-saude-publica-dizem- especialistas.shtml?utm_source=facebook&utm_medium=social&utm_campaign=compfb. Martins, Carlos Eduardo (2018), “9 notas sobre a conjuntura pós-eleitoral brasileira”, Blog da Boitempo, 30 de outubro. Consultado a 19.12.2018, em https://blogdaboitempo.com.br/2018/10/30/9-notas-sobre-a-conjuntura-pos-eleitoral- brasileira/.

209 Tânia Regina Krüger

Mathias, Maíra (2016), “Uma segunda alma para o SUS?”, 9 de novembro. Consultado a 10.04.2018, em http://www.epsjv.fiocruz.br/noticias/reportagem/uma-segunda-alma-para- o-sus. Mathias, Maíra (2018), “Jairnilson Paim analisa os 30 anos do SUS”, Outra Saúde, 22 de março. Consultado a 24.03.2018, em http://outraspalavras.net/outrasaude/2018/03/22/jairnilson- paim-uma-leitura-sobre-os-30-anos-do-sus/. Matoso, Filipe (2018), “Saída de Cuba do Mais Médicos afeta 28 milhões de pessoas, diz Confederação dos Municípios”, G1, 15 de novembro. Consultado a 19.12.2018, em 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. Mendes, Áquila; Funcia, Francisco Rózsa (2016), “O SUS e seu financiamento”, in Rosa Maria Marques; Francisco Sérgio Piola; Alejandra Carrillo Roa (orgs.), Sistema de saúde no Brasil: organização e financiamento. Rio de Janeiro/Brasília: ABrES/Ministério da Saúde/OPAS/OMS, 139-168. Consultado a 05.10.2017, em http://bvsms.saude.gov.br/bvs/publicacoes/sistema_saude_brasil_organizacao_financiam ento.pdf. Miranda, Alcides Silva de (2017), “A Reforma Sanitária encurralada? Apontamentos contextuais”, Saúde em Debate, 41(113), 385-400. Consultado a 29.09.2017, em http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103- 11042017000200385&lng=pt&nrm=iso. Mortanari, Marcos (2018), “Flávio Rocha explica movimento ‘Brasil 200’ e pede presidente liberal na economia e conservador nos costumes”, InfoMoney, 18 de janeiro. Consultado a 25.11.2019, em https://www.infomoney.com.br/politica/flavio-rocha-explica-movimento- brasil-200-e-pede-presidente-liberal-na-economia-e-conservador-nos-costumes/. Nogueira, Marco Aurélio (1998), As possibilidades da política. São Paulo: Paz e Terra. Ocké-Reis, Carlos Octávio (2018), “Sustentabilidade do SUS e renúncia de arrecadação fiscal em saúde”, Ciência & Saúde Coletiva, 23(6), 2035-2042. Consultado a 17.08.2018, em http://www.scielo.br/pdf/csc/v23n6/1413-8123-csc-23-06-2035.pdf. Paim, Jairnilson Silva (2011), “Modelos de atenção à saúde no Brasil”, in Lígia Giovanella; Sarah Escorel; Lenaura de Vasconcelos Costa Lobato; José Carvalho Noronha; Antonio Ivo de Carvalho (orgs.), Políticas e sistemas de saúde no Brasil. Rio de Janeiro: Fiocruz, 547- 573. Paim, Jairnilson Silva (2018), “Sistema Único de Saúde (SUS) aos 30 anos”, Ciência & Saúde Coletiva, 23(6), 1723-1728. Consultado a 11.02.2019, em http://dx.doi.org/10.1590/1413- 81232018236.09172018. PMDB – Partido do Movimento Democrático Brasileiro (2015), “Uma ponte para o futuro”, 29 de outubro. Consultado a 07.03.2019, em https://www.fundacaoulysses.org.br/wp- content/uploads/2016/11/UMA-PONTE-PARA-O-FUTURO.pdf. Reis, Ademar Artur Chioro dos; Sóter, Ana Paula Menezes; Furtado, Lumena Almeida Castro; Pereira, Silvana Souza da Silva (2016), “Tudo a temer: financiamento, relação público e

210 Sistema Único de Saúde: redução das funções públicas e ampliação para o mercado

privado e o futuro do SUS”, Saúde em Debate, 40(n.º esp.), 122-135. DOI: 10.1590/0103- 11042016S11 Santos, Boaventura de Sousa (2018), “Vivemos um ciclo reacionário diferente, que tenta acabar com a distinção entre ditadura e democracia”, El País, 6 de novembro. Entrevistado por Javier Martín 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 de dezembro. 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. Santos, Ronaldo Teodoro dos (2018b), “A Teoria Sanitária e o Momento Corporativo: a crítica de um desafio não superado”, in Sonia Fleury (org.), Teoria da Reforma Sanitária: diálogos críticos. Rio de Janeiro. Fiocurz, 183-220. Sobrinho, Wanderley Preite (2018), “Peso do SUS cai, e saúde privada tem fatia maior do que em países 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 da administração pública brasileira”. Tese de Doutorado em Serviço Social apresentada na Universidade Federal do Rio de Janeiro – Faculdade de Serviço Social, Rio de Janeiro, Brasil.

211 e-cadernos CES, 31, 2019: 212-221

ROSANA MIRALES

DEBATE SOBRE OS FUNDAMENTOS DO CONSERVADORISMO

Resumo: O debate aqui proposto insere-se numa preocupação assumida em estudos anteriores quanto ao impacto 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 de ideologia – aspecto recorrente nas reflexões críticas desenvolvidas em estudos e pesquisas sobre os fundamentos do conservadorismo. A busca do entendimento sobre as metamorfoses adquiridas por esse pensamento social nos diferenciados contextos históricos é confirmada pela obra de Baqués, que identifica uma tendência de aproximação do conservadorismo ao liberalismo. Palavras-chave: conservadorismo, fundamentos, liberalismo, política, teoria.

DEBATE ON THE FOUNDATIONS OF CONSERVATISM

Abstract: The debate proposed here is part of a concern assumed in previous studies about the impact of the 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 in critical reflections in studies and research on the foundations of conservatism. The search for an understanding of the metamorphoses of this form of social thought in different historical contexts is confirmed by Baqués’ work, which identifies a tendency for conservarism to move closer to liberalism. Keywords: conservatism, foundations, liberalism, politics, theory.

INTRODUÇÃO Em estudos mais recentes, propusemo-nos compreender o conservadorismo e as formas por que esse pensamento social e essa ideologia influenciam o Serviço Social, por ser nossa área de atuação e pesquisa (Mirales, no prelo). Sintetizando muito, o conservadorismo influencia o Serviço Social, desde logo, através da reconfiguração das políticas de ensino superior, o que, na situação brasileira, aos poucos modifica a oferta dos

212 Rosana Mirales cursos presenciais para a modalidade a distância e, nesse processo, pode-se identificar a clara preocupação com a diplomação, que não assegura a formação qualificada que a complexidade do trabalho com as políticas sociais exigem. Esse processo força também a reorientação dos conteúdos da formação profissional em favor do processo imposto pelo Estado neoliberal, que adota, sem questionar, as determinações das agências financiadoras externas, as normas para o pagamento da dívida externa e os ajustes fiscais necessários para o andamento da economia do país (Lima, 2002). Embora as entidades que representam os assistentes sociais sintam o impacto do atual contexto regressivo, pode-se dizer que isto ocorre sem as atingir diretamente em sua direção social, por evidenciar o desenvolvimento e as posturas dessas entidades, a contraposição ético- política ao conservadorismo. Contudo, o conservadorismo corrói a sua orientação ético- política, na medida em que contribui para a formação de assistentes sociais no quadro de outra concepção teórico-filosófica que se distancia de uma perspectiva teórico-crítica, e isso com fortes repercussões nas dimensões técnico-operativas da profissão. Neste texto, toma-se, como questão de fundo, a regressividade cultural vivenciada no atual contexto histórico, procurando reavaliar e atualizar os debates sobre o conservadorismo e o seu impacto nas instituições democráticas. Foram incorporadas categorias analíticas que compreendem o conservadorismo como parte do processo de uma “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 baseado num modo de produção que gera desigualdades insuportáveis e recorre ao moralismo como forma de coação sobre a liberdade. Não há condições de esclarecer os argumentos de tais autores em torno do debate, entretanto, tal perspectiva indica um caminho profícuo de análise sobre o pensamento conservador como uma expressão cultural própria da sociabilidade capitalista. Nos levantamentos e nas seleções bibliográficas realizados acerca daqueles debates, identificamos muitos autores em várias áreas do conhecimento que se dedicaram ao estudo do conservadorismo. De entre eles, destacamos o cientista político Josep Baqués que tem contribuído, mais recentemente, para uma síntese das trajetórias do pensamento conservador e, em particular, para a compreensão da atual configuração da associação do pensamento conservador com o pensamento liberal. O primeiro texto identificado 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 necessário sobre o tema.

213 Debate sobre os fundamentos do conservadorismo Os referenciais teórico-metodológicos adotados por Baqués aproximam-se da teoria social de Max Weber. Baqués busca, por meio da análise de autores previamente selecionados pelas suas posturas conservadoras, a construção de variáveis e de tipos ideais. O que se pretende, neste texto, é expor a obra de Baqués (2017), dada a sua relevância para os estudos sobre o conservadorismo e, posteriormente, apresentar alguns contributos para a análise teórico-metodológica de uma categoria relevante no contexto da obra, que é a ideologia.

O LIBERALISMO-CONSERVADOR: FUNDAMENTOS TEÓRICOS E RECEITUÁRIO POLÍTICO DESDE O

SÉCULO XVIII O livro de Baqués, lançado em 2017, enfatiza a continuidade histórica na formulação, na ação política e nas formas de influenciar a realidade e a cultura, por meio da difusão de valores 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 ao longo do tempo, se reafirmam em argumentações que sedimentam a sua rearticulação nesse 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 que sustenta a parede histórica da apologia burguesa ao modo de produção.

A hipótese que proponho (a primeira hipótese desta pesquisa), em relação aos seus argumentos, é que o conservadorismo moderno tem um “núcleo duro” doutrinário suficientemente compacto e homogeneo como para poder falar de que estamos ante uma ideologia consolidada. Portanto, o meu trabalho consistirá na busca e descoberta, quando apropriado, do que poderíamos definir como o “denominador comum” de todas estas correntes. (Baqués, 2017: 57; itálico no original)1

O autor move-se pelo objetivo de compreender o conservadorismo contemporâneo, em particular o americano e, para isso, remete para a trajetória dos principais formuladores desse pensamento, deixando clara a sua perspectiva de análise: “Mas, por outro lado, recuso-me a pensar o conservadorismo moderno prestando atenção apenas a autores e obras escritos no contexto da crise do petróleo dos anos setenta [do século XX]” (ibidem: 50), e segue com a argumentação:

1 As traduções da obra de Baqués foram realizadas pela autora.

214 Rosana Mirales [...] a segunda hipótese a ser demonstrada nesta análise é que as verdadeiras raízes do conservadorismo moderno devem ser buscadas em algum ponto na “encruzilhada liberal-conservadora”, uma encruzilhada que existe há quase três séculos e que, muito particularmente, pode ser encontrada no seio da Ilustração escocesa. (Baqués, 2017: 62; itálico e negrito no original)

Em outras palavras, o autor propõe-se realizar uma radiografia da ideologia liberal- conservadora. Baqués analisou o pensamento de seis autores clássicos, situados entre os séculos XVIII e XIX, e seis contemporâneos, do século XX. A partir do posicionamento desses autores procurou construir um tipo ideal, no sentido weberiano, buscando chegar ao que considera o “núcleo duro” do conservadorismo. E, sem perder de vista as especificidades, propõs-se a demonstrar as pequenas diferenças dos diversos autores, afirmando não haver contradição entre elas. Aos autores considerados clássicos – David Hume, Adam Smith e Adam Ferguson – adicionou pequenos detalhes da obra de Edmund Burke e Alexis de Tocqueville, e considerou que o pensamento político de Herbert Spencer remete para as ideias libertárias num quadro que classificou de anarco-capitalismo ou anarquismo “de direita”. Entre os contemporâneos, considerou como sendo conservadores Friedrich Hayek, Michael Oakeshott, Michael Novak e Irving Kristol e como libertários ou anarco-capitalistas Robert Nozick e Murray N. Rothbard. Tendo em conta essa tipificação para situar o posicionamento dos conservadores, Baqués acredita ser possível demonstrar a continuidade entre clássicos e contemporâneos e, também, os fundamentos teóricos desse pensamento social. De um lado, ele situou os defensores do liberalismo social e, de outro, as formas de expressão mais recentes, como os neoconservadores americanos, como o movimento Tea Party – organizado no interior do Partido Republicano nos Estados Unidos da América – e/ou os populismos “de direita”, salientando os elementos que dão continuidade à “cosmovisão” ou à ideologia conservadora. O objetivo principal da obra de Baqués (2017) é demonstrar que há autores que podem ser diretamente definidos como liberais-conservadores e que o liberalismo-conservador contém um corpo teórico suficientemente denso para ser considerado uma ideologia capaz de colocar perguntas e oferecer respostas que competem com alternativas como o liberalismo social ou radical, a social democracia, o comunismo, o fascismo, etc. O segundo objetivo é demonstrar que o liberalismo-conservador não é uma mera reação contra a ideia de progresso. As origens do liberal-conservadorismo remontam à Revolução Francesa e podem, pois, ser vistas como derivadas de outra postura, que oferecia uma leitura própria de natureza humana, da filosofia da história, da liberdade ou da igualdade, dos valores e do papel do Estado na vida das pessoas.

215 Debate sobre os fundamentos do conservadorismo A análise do pensamento dos autores fez-se a partir de um conjunto alargado de variáveis, capazes de configurarem um tipo ideal de liberalismo-conservador: 1) filosofia da história, 2) racionalismo e política, 3) moral universal versus morais contextualizadas, 4) teoria do direito, 5) democracia, 6) papel do Estado (relação entre Estado e mercado) e 7) sistema de transmissão de valores. A partir delas, Baqués faz uma análise comparativa entre os seis autores clássicos e os seis contemporâneos, considerando que as três primeiras variáveis respondem aos fundamentos teóricos adotados pelos autores, a quatro e a cinco aos valores nucleares da ideologia, e a seis e a sete a questões relativas à prática política. Sem detalhar os pormenores da análise realizada pelo autor, tentamos expor a sua síntese, quanto à definição de tipo ideal do liberalismo-conservador. Em relação à segunda hipótese, ou seja, as verdadeiras raízes do conservadorismo moderno, Baqués considera que ela pode ser demonstrada em dois sentidos: no tempo e no espaço, ou seja, observa coincidências nas obras de Hume, Hayek e Kristol; ou como elementos de continuidade entre aqueles que foram, por ele, considerados “ilustrados escoceses” conservadores, e os modernos, como, de um lado, Hume, Adam Smith e Adam Ferguson e, de outro, Hayek, Oakeshott, Kristol e Novak.2 Detalhando um pouco mais a análise de Baqués (2017: 538) quanto à primeira hipótese, que o conservadorismo moderno se constituiu como uma ideologia consolidada, ele mostra existir um núcleo comum compartilhado entre as diferentes famílias ideológicas que compõem o conservadorismo moderno. Entre os autores, identifica mais os elementos que os unem do que os que os diferenciam e estes não afetam o modelo de sociedade defendido por todos. Nas seis primeiras variáveis analisadas, indica Baqués serem 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, nas palavras de Baqués, como “cimento social”, embora em Kristol e Novak estejam mais presentes os argumentos de uma “crise moral”, do que em Hayek e Oakeshott. Na sequência da análise, Baqués interroga-se se o pensamento é “liberal” ou “conservador” e responde que é ambas as coisas:

2 No que diz respeito a Burke, Baqués destaca que existe um encadeamento entre ambos os discursos conservador e liberal. Quanto a Tocqueville, ele considera o seu pensamento um “denominador comum”, quando tomadas para análise as variáveis mais orientadas para a prática política (3, 4, 5, 6 e 7), e considera que, com as alterações que o próprio autor promoveu na sua obra, relacionadas com a providência e a negação do cartesianismo no âmbito político, tornou-se um “pensador-ponte” entre o conservadorismo e o liberalismo. Spencer, por sua vez, distancia-se de vários pensadores que foram considerados para análise, nas variáveis 1, 3 e 7. Contudo, há coincidências relativas às variáveis 2, 4 e 6, e diferencia a sua análise quanto à variável 5.

216 Rosana Mirales [...] uma ideologia “liberal-conservadora” é capaz de integrar desde o início [...] elementos prórpios dessas duas grandes caixas de alfaiate [algo onde cabe tudo]. E não apenas, como se foi vendo, no que diz respeito à questão de buscar a “moral mais adequada para o capitalismo”, mas também, é claro, em relação às outras questões levantadas, sem exceção. (ibidem: 539)

Baqués destaca, na análise das variáveis adotadas, o distanciamento dos libertários. Em Rothbard, tal distanciamento dá-se nas variáveis 1, 2, 3, 5 e, em parte, nas 6 e 7, sendo que 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, há aproximações a Hayek. Portanto, para Baqués, há evidentes afinidades em nove dos autores analisados, que podem ser considerados próximos do liberalismo-conservador. Quanto a Spencer, há reservas nesse sentido; Nozick mostra ter pontos de coincidência; e em Rothbard existe um maior distanciamento, o que permite concluir que as maiores aproximações se dão entre os autores que não são considerados libertários. Tendo em vista, então, a aproximação entre os clássicos Burke e Tocqueville, assim como entre os contemporâneos Hayek, Oakeshott, Kristol e Novak, e a aproximação em alguns pontos de Spencer e Nozick, Baqués explicita o tipo ideal construído sobre o liberal- conservadorismo, apontando as seguintes características: ‒ alguma defesa da teoria da evolução, com certa tendência para uma visão “naturalista”, o que, supostamente, retiraria a possibilidade de um posicionamento político; ‒ visão do ser humano como ignorante por natureza, descarte da possibilidade de decisões racionais; mas admissão do uso de uma racionalidade instrumental que leve o ser humano a uma melhor adaptação aos fins predeterminados, derivados do processo evolutivo; ‒ teoria do direito baseada na primazia da propriedade privada, da liberdade negativa e da igualdade perante a lei; ‒ moral e direito referenciados na retórica dos direitos naturais; e relativismo moral com base na procura de uma proximidade com o jusnaturalismo e o positivismo; ‒ suspeita da incompatibilidade entre democracia e proteção dos direitos e/ou instituições responsáveis pela ordem espontânea da evolução, com aceitação formal da democracia representativa e recusa de qualquer prática participativa; ‒ quanto ao Estado, por um lado, há perspetivas que recusam a justiça social e desautorizam práticas redistributivas, apelando à benevolência privada de cunho

217 Debate sobre os fundamentos do conservadorismo 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 essa segunda postura, as ajudas não se justificam pelo respeito a direitos desses sujeitos, mas pela salvaguarda dos direitos dos demais, perante possíveis atos de “desespero” daqueles; ‒ apelo às religiões e ao nacionalismo, o que reforça a “moral capitalista”. Baqués destaca que a relação existente entre o moderno conservadorismo e essas práticas é meramente instrumental. Delas resultam uma dupla função: atuam como “cimento social”, para garantir a paz social, inclusive em crises prolongadas e contribuem para diminuir o impacto que o excesso de individualismo, hedonismo/consumismo tem sobre a “moral capitalista”. Para alguns autores analisados, a continuidade do capitalismo depende da sobriedade e do controle moral requeridos.

ANÁLISE DOS FUNDAMENTOS DO CONSERVADORISMO E IDEOLOGIA 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, ou seja, como cosmovisão (Weltanschauung) ou visão de mundo. Nesse sentido, chamamos a atenção ao amplo debate que envolve a questão. Referimo-nos a Iasi, que recupera esse debate desde as formulações de Hegel sobre os processos de externalização, a partir do qual 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 idealismo objetivo de Hegel, compreende esta efetivação (Verwirklichung) da consciência no mundo como algo real (uma efetividade inabalável) que ganha uma independência em relação à consciência mesma que o produziu, levando, necessariamente, ao processo de estranhamento. (Iasi, 2014: 98)

Indica Iasi (2014), que os avanços de Marx e Engels quanto a mesma questão, deram- se por terem decifrado que nem toda objetivação e externalização implicam o estranhamento, atribuindo então a sua explicação, na sociedade capitalista, à mercadoria. Logo, a questão do estranhamento, nessa perspectiva, não está situada na consciência humana, mas na objetividade das relações. Ainda segundo Iasi (ibidem: 101), Marx e Engels também demonstraram que “Os seres projetam as suas representações para fora de si mesmos e elas acabam se voltando contra eles como uma força estranha que os controla”, o que exige compreender os indivíduos como seres sociais, inseridos em determinadas forças produtivas e relações sociais de

218 Rosana Mirales produção. Nesse sentido, o debate levado por Marx (1997) que desloca a análise da religião para o Estado, demonstrando que nas relações de produção, mediadas pela mercadoria, ocorre um movimento que às vezes gera a inversão das explicações sobre a realidade: “Fica evidente que os autores não tratam a ideologia como mero conjunto de representações ideais, ou uma visão de mundo, mas como uma inversão” (Iasi, 2014: 103). Quanto ao estranhamento resultante do processo, Iasi analisa que o fundamento do caráter histórico do ser social e das suas dimensões ontológicas produzem novas necessidades e, também, se associam a determinada forma de produção da vida e, nesse contexto, apresentam singularidades em sua existência. A linguagem e a consciência podem ser tomadas como momentos constitutivos da singularidade humana, pois, nesse âmbito, operam as distinções entre as dimensões materiais e espirituais. Ocorrem os “reflexos ideológicos” ou “sublimações necessárias”, em que a consciência se emancipa do mundo. Assim, as representações “[...] expressam uma necessidade, mesmo e principalmente, através de seu caráter de inversão, de ocultamento, de estranhamento” (ibidem: 106) e, portanto, há uma distinção entre as formas de consciência e a ideologia, o que leva Iasi a compreender, que para Marx e Engels, “toda ideologia é uma forma de consciência; no entanto, nem toda forma de consciência é ideológica” (ibidem). Nesse sentido, a ideologia presente na estratégia conservadora, a nosso ver, é a base de sustentação histórica, como força política, de reprodução e de ampliação do capital, ou, como de uso frequente entre marxianos, constitui-se em uma apologia burguesa à continuidade histórica do capitalismo. Portanto, o entendimento do pensamento conservador, como movimento que se articula no contrário das conquistas possíveis postas na modernidade, torna-se para nós mais consistente. Conforme Baqués demonstra, os elos comuns entre o pensamento conservador, apresentado pela análise dos autores que compõem o quadro histórico de sua trajetória, revelam uma doutrina coerente. Posto na

Revolução Francesa, no final do século XVIII, tal pensamento social articula-se e reproduz- se historicamente na proximidade, maior ou menor, com o liberalismo, de acordo com as necessidades históricas conjunturais e o que se revela mais ou menos evidenciado nas posturas de um ou outro autor situado nesse pensamento social. Assim, compreender tal movimento como um processo que compõe a decadência burguesa, parece-nos bastante apropriado, visto que o seu caráter reacionário aos avanços do desenvolvimento se fundiu com as justificativas da continuidade histórica do capitalismo. A burguesia abriu mão das conquistas do Iluminismo para seguir em conjunto com forças que, em primeiro momento, tentaram aniquilar o desenvolvimento histórico de uma determinação posta na transição do modo de produção feudal ao capitalismo. A base de sustentação de tal pensamento constitui-se nas forças produtivas; entretanto,

219 Debate sobre os fundamentos do conservadorismo conservadores e liberais lançam mão reiteradamente, ao longo dos séculos, de argumentos situados no plano da linguagem e da consciência, operando com recursos como aqueles adotados nas argumentações assentes nos moralismos, como estratégia de sustentação da sociabilidade burguesa. Porém, a consciência é fruto da situação objetiva de sua condição. E para seguir com as argumentações sobre ideologia, Löwy defende que “[...] existem poucos conceitos na história da ciência social moderna tão enigmáticos e polissémicos quanto o de ‘ideologia’ [...]” (1998: 9-10). Para dizer de forma simples, o autor explica, demonstrando a invenção do termo ideologia por Destutt de Tracy, em 1801; a sua adoção por Napoleão Bonaparte; e a forma como Lenine a difundiu: “[...] a ideologia designa o conjunto das concepções de mundo ligadas às classes sociais, incluindo o marxismo” (Löwy, 1998: 10; itálicos no original). Löwy destaca ainda a confusão e ambivalência ocorrida no debate sobre ideologia, não só no debate entre autores, nos seus posicionamentos, podendo inclusive se encontrar tal ambivalência em uma única obra. Quando Löwy analisa a obra Ideologia e Utopia de Karl Mannheim, ele discorda sobre a forma como foram reunidas as duas categorias e ambas consideradas como “falsa consciência”,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 em Marx. O autor conclui que o que Mannheim considerou “ideologia total” – e que pode ser ideológico ou utópico –, corresponde ao conceito de Weltanschauung, ou seja, a uma visão 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 destas formas), nem conservador nem revolucionário. Ele circunscreve um conjunto orgânico, articulado e estruturado de valores, representações, idéias e orientações cognitivas, internamente unificado por uma perspectiva determinada, por um certo ponto de vista socialmente condicionado. (ibidem: 12-13; itálicos no original).

E para finalizar, Löwy acrescenta que, ao Mannheim incorporar social ao conceito ideologia, retira a possibilidade de ser entendido na relação com o cosmos ou à natureza enquanto tais, mas ao “[...] conjunto relativamente coerente de idéias sobre o homem, a sociedade, a história, e sua relação com a natureza”; e assim sendo, a visão de mundo

3 “Quanto ao conceito de “falsa consciência”, este nos parece inadequado porque as ideologias e as utopias contêm, não apenas as orientações cognitivas, mas também um conjunto articulado de valores culturais, éticos e estéticos que não substituem categorias do falso e do verdadeiro.” (Löwy, 1998: 12).

220 Rosana Mirales 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 a elementos utópicos, pois em dado conjuntura pode ser utopia e em outra circunstância histórica, manifestar-se como ideologia. Observa-se, portanto, primeiro, que o liberalismo-conservador estudado por Baqués (2017) constitui uma das estratégias ideológicas que justificam a ampliação das relações sociais de produção em bases capitalistas; e, depois, que as consequências nefastas que o neoliberalismo trouxe e continua a trazer, assumem, na atual conjuntura, uma hegemonia que o conduz de forma conservadora e também reacionária.

ROSANA MIRALES Universidade Estadual do Oeste do Paraná, Campus de Toledo, Rua da Faculdade, 645 – Jardim La Salle, CEP: 85903-000, Toledo-Paraná, Brasil Contacto: [email protected]

REFERÊNCIAS BIBLIOGRÁFICAS 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. Iasi, Mauro Luis (2014), “Alienação e ideologia: a carne real das abstrações ideais”, in Marcos del Roio (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 campos de exploração”, in Maria Lúcia Wanderley Neves (org.), O empresariamento da Educação. Novos contornos 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”, Praia Vermelha, 29(2), 715-740.

221 Editada pelo Centro de Estudos Sociais desde 2008, a e-cadernos CES é uma publicação eletrónica, disponível em https://journals.openedition.org/eces, com arbitragem cientí ca que visa promover a divulgação de investigação avançada produzida no âmbito das ciências sociais e humanas, privilegiando perspetivas críticas e inter/transdisciplinares. A e-cadernos CES dissemina textos resultantes de conferências, seminários e workshops, assim como textos de pesquisas efetuadas no âmbito de programas de formação avançada e de projetos de investigação cientí ca.

www.ces.uc.pt Colégio de S. Jerónimo Apartado 3087 3000-995 Coimbra, Portugal Tel. +351 239 855 570 Fax. +351 239 855 589