Understanding the impact of the economic crisis on child health: the case of Spain

Understanding the health impact of the Great recession on specific vulnerable groups such as children is important to inform policies at national and international levels. The current crisis has affected the whole European economy, but the potential impact on health in each country depends on several factors including the starting point; mechanisms of social protection and social transfers; and the measures adopted by governments to deal with the crisis [1].

Three phases of the crisis have been described [2]. The first wave (economic impact) was characterised by job losses and reduced household incomes in many countries. The second wave (social impact) was characterised by a high levels of unemployment particularly affecting younger people, increasing the numbers neither in employment nor in education or training (NEETs). The third wave (unequal recovery), that authorities and some media are claiming started in 2014, has been characterized by a slow, uneven return of growth to trend with some areas recovering quickly but other areas remaining in recession.

Spain has been hit hard by the Great recession [3]. The Welfare state in Spain was created more recently than in other western European countries, after the period of dictatorship. The Spanish society and economy inherited a protected and conservative financial sector, an insufficient and regressive fiscal system, and scarcity of social protection and benefits. Consequently, the pre-crisis welfare state was less comprehensive than in other European countries [4]. In this situation any reduction of the welfare state is likely to result in even weaker social protection than in other contexts [5, 6].

Although there are many potential differences between countries, recessions pose risks to health of the general population [7]. Mental health problems, infectious diseases and suicides are becoming more common in countries affected by the economic crisis [8].

It is universally recognised that children represent a particularly vulnerable population group. Inequalities in early child development have been identified as a major contributing factor to inequalities in adult health, depending on the balance of adverse exposures and protective factors in early life [9, 10]. Few studies have been published to date on the impact of the current crisis on children’s health [11, 12] and the responses of specific governments [7], particularly in terms of the potentially mitigating or harmful effects of public policies affecting family economic security and social conditions [13]. The objectives of the present work were therefore to explore effect of the crisis on child health using Spain as a case study, and to document and assess the policies that have been implemented in response to the crisis in this context.

A descriptive and exploratory study was conducted using mixed-methods approach. Routinely available data pre-and post crisis was analysed to monitor social determinants of child health. Periodic Spanish National Health Interview Survey (NHIS) and the Minimum Data Set of Hospital Discharge (MDHD) was used to check changes in health behaviours and mental health indicators during the study period, and synthesis of data on key policies that have influenced families with children was analysed to describe government responses. We sought to analyse trends in key social determinants affecting children (poverty and material deprivation); and child health outcomes. A content analysis of the data sources on legislation and a recent supplement published by the Spanish Society of Public Health [3] was used to describe austerity measures. Where possible we sought to identify any differential effects of policies on the basis of socioeconomic status, to test the hypothesis that more vulnerable groups have been disproportionately affected by the crisis, and some of the policy responses in Spain.

The study results show a significant deterioration in the social determinants of child health since the crisis and over the period during which austerity measures have been implemented, with increasing social inequality and child poverty. We do not find any immediate effect on child health at general population level but there is evidence of an impact on vulnerable groups.

Among the limitations of the present study should be mentioned the lack of updated and disaggregated data on child population to study the impact on small areas or vulnerable groups. Moreover, the analysis of population average indicators can mask inequalities in specific population subgroups. Secondly, there are difficulties in establishing a causal association between austerity measures and health outcomes. Available data do not allow analysis of the association between social determinants and health outcomes because these aggregate data come from different sources and cannot be easily combined. Further studies using small area or individual level data are recommended to address these questions. Furthermore, longer term follow-up is required to assess the plausible long-run impacts of a deterioration in the social determinants of child health.

The budget cuts in public education have affected the possibility of promoting a more equitable growth and development and early socialisation of children have been reduced in areas with greater economic deprivation [18]. The budget constraint has also affected school canteens. This fact is associated with increased difficulty in providing adequate food especially to the most vulnerable groups, and possibly perpetuates existing inequalities in childhood obesity according to family education level [12, 19].

Difficulties to maintain housing have deteriorated alarmingly, either to pay the mortgage or rent for families with scarce resources. The Spanish laws before the start of the current crisis unfairly penalised those who cannot pay their mortgages. This fact has been worsened by rising unemployment and precarious working conditions of many families due to the economic crisis. Moreover, the increase in the price of energy has increased the difficulties of families to meet their basic needs for water, electricity, heating, etc. These factors have shown a large negative impact on child health of these vulnerable groups [15].

Spain is one of the developed countries with highest increase in the percentage of children at risk of poverty [20]. One in three children in Spain lives at risk of poverty, according to the latest available data. In the face of cuts to welfare support, NGOs have seen a dramatic increase in demand for services since the onset of the economic crisis. Thus, NGOs have tripled the number of families attended since the beginning of the crisis by problems of housing, food or social support while public investment in child protection has declined [21, 22]. Romania, Spain, Bulgaria, Greece and Italy share the highest rates on child poverty and low impact of family and childhood benefits. Moreover, it has been shown a greater impact in children compared with other general population groups [18], similar to what happens in other countries [23, 24].

Social determinants of child health have deteriorated and social inequalities affecting children have increased in Spain with the economic crisis, a fact known to be associated with worse health outcomes in the medium and long term, according to the evidence from previous studies [25]. As part of the response to the crisis, successive Spanish governments have established austerity measures and structural changes in labour protection, as well as in social and health care systems [26]. These measures are affecting families with fewer economic resources, families with all members unemployed, long-term unemployed families, and single parent unemployed families.

The childhood population under 18 years old legally continues with universal access to healthcare services after the promulgation of Decree Law 16/2012, which breaks the universality of access and changes the paradigm of the Spanish healthcare system [27]. However, some cases of healthcare exclusion in children have been reported and variability in the application of the above mentioned decree has been found. Some regions of Spain continue with the previous system without barriers to access while in other regions the decree is variably applied. These barriers to population subgroups, such as migrants in an irregular situation, are associated with an indirect impact on the child population and insecurity in families in these conditions, which are usually those who need more support and access to preventive measures and healthcare services. Likewise, the increase in copayments generates greater difficulty in the most vulnerable groups. The results of the present study are consistent with those of another study that analysed the austerity measures in Europe and showed that they can exacerbate the short-term public health effect of economic crisis [7].

The finding that, despite the impact of austerity in Spain on the social determinants of child health, a short-term impact on child health has been detected only in specific population subgroups and not in the general child population is counter-intuitive and challenges the hypothesis that austerity is detrimental to the health of child populations. Previous studies found poor mental health in the adult population [8] with an increase of 19 % in the percentage of mood disorders, 8 % in anxiety, and 5 % in alcohol abuse after the crisis started, and these increases were associated with unemployment and housing problems. Increased incidence of suicide attempts in the general population was also found [28]. We have not detected changes in children’s mental health trends nor an increase in child maltreatment, effects that were found in a systematic review of the impact of the current crisis in child health [11]. It is likely that, besides the scarcity of data, families play a protective role in Spain, maybe greater than in other contexts. It could be that families take a palliative and resilient role against the negative effects of the crisis. However, if family stress becomes chronic it can cause depletion of family resources. Moreover, according to the conceptual model and the available evidence, the effect of worsening social inequalities in childhood has consequences for the distribution of health in adulthood [8], and specific changes in law that counteract growing income inequalities through the tax, labour, and welfare systems could have sizable benefits for population health and health disparities.

In conclusion, this study aimed to summarise the evidence about the impact of the economic crisis and austerity measures on social determinants and child health. The impact of austerity policies has likely increased child poverty and deprivation with likely effects on child health especially among vulnerable groups. The findings of this case study suggest the need to urgently protect vulnerable groups of children from the impact of austerity.