Social Inequality, Economic Crisis and Health in Spain
The state of health of the Spanish people, in general terms and in comparison with countries in the same socio-economic bracket, is good. However, there are differences in results relating to the health of individuals according to their socioeconomic situation. These inequalities may be being exacerbated by the economic crisis, which could contribute towards consolidating an increase in morbidity (i.e. the proportion of people who fall ill), due to the increase in unemployment and the stagnation of social mobility.
Programmes and actions are needed with a population-based approach (i.e. focused on analysis of the population) to reduce inequalities in health-related matters along with the need for new resources for the adequate functioning of the healthcare system. These new resources are needed as a consequence of changes that the economic crisis has wreaked on the population’s epidemiological profile which, in addition to morbidity, also takes into account mortality and risk factors in general.
The economic crisis is having negative effects on wellbeing and living conditions among the Spanish population. This deterioration is having a more severe effect on those people who already started off in a more vulnerable situation in terms of life opportunities. In the debate on the welfare state and on how the evolution of the socioeconomic structure affects life opportunities, social class has played an important role. However, it is still necessary to make deeper inroads into analysing the effects on social groups in order to be able to design effective policies that facilitate the battle against inequality.
2. Economic Recovery: Lights and Shadows
The figures that reflect the state of the economy on a macroeconomic level are showing a weak recovery. The Gross Domestic Product is growing at a rate of around 0.8% and although the unemployment rate stands at 21%, employment grew by around 0.7% in the second quarter of 2016 (Banco de España, 2016). For their part, the qualitative indicators that reflect perceptions on the state of the economy, such as the Consumer Confidence Index and the Business Confidence Index are showing a positive trend.
However, this improvement in quantitative and qualitative indicators does not appear to be resulting in greater wellbeing for citizens or a reduction in inequality. Specifically, social protection rates are falling and the distribution of wealth is changing in such a way that inequality between individuals with higher incomes and those on lower incomes is increasing.
With respect to social protection, in the European Union expenditure per inhabitant has increased from 6,680 euros in 2008 to 7,566 euros in 2012, with an accumulated growth of 12.7% (Spanish Ministry of Employment and Social Security, 2014). In Spain, during the same period, expenditure per inhabitant grew from 5,483 euros to 6,027 euros. With respect to national coverage, the rate of unemployment benefits has decreased from 72.8% of unemployed people in 2008 to 55.8% in 2015. The average number of people receiving unemployment benefits in 2015 was 2.2 million, with a fall of 27% with respect to 2010. The average monthly expenditure per beneficiary has fallen since 2012, from an average of 920.3 euros per beneficiary to 791 euros in 2015, a drop of some 14% (CC.OO., 2016).
In relationship with income distribution, according to Eurostat estimates, over 13.5 million people are at risk of poverty and social exclusion, three million more than before the crisis. These data refer to people that have an income below 60% of the average income. The Spanish poverty rate stands six points above the European average. The AROPE (At Risk of Poverty or Social Exclusion) indicator which measures the population at risk of poverty, severely materially deprived or living in a household with a very low employment intensity increased from 24.5% in 2008 to 28.6% in 2015 (INE, 2016). If we break down the data, between 2008 and 2014 this indicator increased for young people aged between 16 and 29 years (11.3% for males and 15.8% for females) and decreased for people aged over 65 years (14.7% for males and 11.5% for females).
In addition to the generational difference, a highly unequal distribution of the risk of poverty or social exclusion exists according to income. In the Gini index, which measures inequality in income, a coefficient of 0 corresponds to perfect equality (everyone has the same income) while a coefficient of 100 corresponds to perfect inequality (one person has all the income and the rest have none). This index has increased during the period of the crisis by 2.4 points and now stands at 34.7 points, whereas for the eurozone it has increased by 0.5 points and stands at 30.9 points (Eurostat, 2016). If we look at the distribution of wealth by income levels, the percentage of the population positioned in the middle strata has fallen by 6 points, with the weight of the lower strata increasing by 7 points and the higher strata maintaining their position (Fundación BBVA, 2016).
It seems, therefore, that although the country has started to leave behind the extremely harsh conditions of the economic crisis, its social consequences are still making themselves felt and not all social groups are benefiting from economic growth and the distribution of wealth equally. To be able to understand the effects of the economic crisis on the wellbeing of citizens, we need to be more aware of its effects on the social structure.
3. Understanding social inequality in Spain: the effect of the crisis
Despite the theoretical differences in the schools of thought regarding the definition of social classes, their empirical application largely converges and organises the social structure in line with income size. It is related, therefore, with the purchasing power that can be achieved through work, inheritance, effort and talent. Simplifying this analysis of the classes we find, firstly, white collar workers who mainly form part of the services sector with medium- and high-level qualifications and, secondly, blue-collar workers, with jobs that demand physical effort, and who are differentiated in turn between qualified and unqualified workers (Martínez García, 2014).
One initial approach to seeing how the economic crisis has affected social inequality is to analyse the evolution of distribution of the employed population by social classes. One can observe that between 2007 and 2012, the volume of employed people among the white-collar social classes has remained at similar levels, while among blue-collar workers it has fallen (5 percentage points for qualified workers and 2 points for non-qualified workers) (Martínez García, 2014). The fall in the employed population of 3 million workers is concentrated largely in the construction sector, which employs a large percentage of the blue-collar workers.
We can also see how the crisis has affected the social classes differently by comparing unemployment rates. Here one can observe that the unemployment rate is significantly higher among the blue-collar classes (35.2% among qualified workers) than among white-collar workers (2.7% among management and business executives) (Martínez García, 2014). Finally, it is interesting to confirm the differences between the social classes in terms of the loss of purchasing power. In relative terms this loss has been greater for the blue-collar classes (around 14.9% for qualified workers and 18.1% for non-qualified workers) than for the white-collar workers (around 8.1% for executives) (Martínez García, 2014).
This description of the Spanish population introducing social class shows that the crisis has worsened the living conditions of the majority, even though the effect is unequal and is weaker on those who were better off before the crisis. In the following section we analyse how the situation of inequality can be made visible in specific dimensions of our wellbeing, and see how the state of health has worsened more among the more disadvantaged social classes.
4. Inequalities in health
The Spanish population has attained a good state of health. In Graph 1, we see how life expectancy has grown at a pace significantly above the average for the OECD countries. Life expectancy is a reflection of the evolution of the main variables (work, education, living conditions, infrastructures, etc.) that affect our state of health. Among the OECD countries, only Japan (83.4 years) beat Spain in terms of life expectancy (83.2 years) in 2013. If we break down this indicator we obtain more information on its distribution among the population. One first interesting variable to observe is age. In terms of average expectations of years of healthy life, for people born today Spain occupies a position significantly above the average. However, with age, the difference between Spain and its peer countries narrows, becoming negative for women currently at retirement age (OECD, 2014). In other words, on average, elderly people in Spain live more years than the average of the OECD but with a poorer level of health.
It is also interesting to see whether there are differences in health results according to the education level attained by citizens. Graph 2 shows the relationship between prevalence of chronic illnesses and educational level of individuals. In all cases, the greater the educational level, the lower the prevalence of chronic illness. Without entering into causality we see, therefore, that educational levels are important for understanding the differences in terms of health and we find markedly different epidemiological profiles depending on the education level of the individuals.
Together with differences by age and educational level, we observe that social class is also relevant and that there is a variation favouring the privileged classes against the less privileged classes. Thus, for example, Graph 3 shows how the percentage of people who consider that their health is very good or who perceive that they have a chronic health problem progressively diminishes as we move along the social class axis, described according to occupation.
The social variation is not only observed in subjective health but also in objective health, both physical and mental. Graph 4 shows how two of the chronic diseases with the highest prevalence in Spain also have a social variation. Similarly, as illustrated in Graph 5, mental health problems also appear with greater frequency in the most disadvantaged social classes, both among the adult and child populations alike.
In terms of the population’s health, we can conclude, therefore, that although Spaniards have attained a life expectancy among the highest of its peer countries, when stratifying the health level of the population by age, education or social class, a very significant degree of inequality can be appreciated. It can also be observed that in terms of healthy years of life expectancy for groups of advanced age, Spain is at levels close to or below the average of peer countries in the same socioeconomic environment. In the following section we will see how the economic crisis may be associated with greater social inequalities in health.
5. The economic crisis and health
The economic crisis has generated a notable increase in long-term unemployment in Spain. Lack of resources and the stress associated with unemployment cause deteriorations in wellbeing and worse health among affected people and households. The probability of an unemployed person stating that their perceived state of health is “average, poor or very poor” is 28% higher than that among employed people (INE, 2013). A long-term unemployment rate above the pre-crisis level may lead to an increase in morbidity among the more affected groups, as well as meaning additional demands on the resources of the healthcare system.
As we have seen, the results in health and the prevalence of chronic diseases in Spain are subject to significant socioeconomic variation. In this sense, the social mobility of the more disadvantaged social classes towards higher levels could be an indirect mechanism for improving the population’s epidemiological profile in the long term. However, the economic crisis may be creating an obstacle to this mechanism because, fundamentally due to unemployment, it has increased inequality levels in Spain. Recent studies show that increases in income inequality levels contribute to a reduction in social mobility towards better positions (OECD, 2015). Thus, to the extent that the economic crisis has generated inequality, it could in turn contribute towards stagnating or worsening the epidemiological profile of society overall.
Furthermore, there is growing evidence on the effect of the economic crisis on certain disorders (e.g. mental illnesses) and health risk factors (e.g. obesity). In the same direction, some recent studies have associated unemployment with higher suicide rates, anxiety disorders and chronic depression. In Spain, the probability of suffering from chronic mental disorders among unemployed people is double that existing among employed people (INE, 2013).
With respect to risk factors for health, the economic crisis and lesser social mobility could have contributed to the increase in excess weight gain and obesity in Spain through changes in diet generated by falls in income or higher levels of stress due to financial reasons. Thus, the medium and long term could see consolidation of the higher number of individuals in socioeconomic groups with lower educational levels at a greater risk of suffering from excess weight gain and obesity. To the extent that the crisis favours social stagnation, consolidation of the number of citizens in these socioeconomic groups could contribute to levels of obesity and excess weight gain failing to decrease in Spain in the future.
6. Some recommended measures and actions
Social inequalities in health, together with the ageing of the Spanish population and the consequent increase in the resources necessary for treating chronic diseases, require a series of measures aiming to reduce inequalities, improve the performance of the healthcare system and guarantee its sustainability in the long term.
There are many measures and possible areas for action (innovation, assessment, restructuring of healthcare system supply and demand) but perhaps it is a good idea here to focus on the recommendation of the use of the population-based approach (used successfully by the World Health Organisation, or in countries such as Canada and Australia) for improving the health levels of the population and reducing inequality. Based on quantitative and qualitative analysis, the population-based approach identifies population clusters according to their health level and the variables determined by those health levels. The identification of population groups enables the designing of care plans focusing on the needs of these groups. It also facilitates the development of care programmes and campaigns that concentrate the use of resources on certain groups with poor health levels. In this sense, interventions with a population based approach can combat the origin of health problems in the long term and of the health system overall by tackling, for example, the health problems of generational groups with potentially greater healthcare needs in the future.
In Spain, the definition and development of policies around a population-based approach may reduce inequalities in health and the pressure on the system as a consequence of the tendencies projected in the population’s epidemiological profile (i.e. greater prevalence of chronic illnesses, the growing problem of obesity and the worsening of mental health in population groups affected by the economic crisis). In this sense, it is particularly important to underline the social variation that exists in all of these challenges. The application of a population-based approach to tackle these challenges involves making available a detailed analysis of health inequalities in Spain.
Elisa Díaz Martínez, Ideas Laboratory Director
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