Quick remarks onQuick remarks on Economics and HealthEconomics and Health

Vicente OrtúnVicente OrtúnMadrid, October 22Madrid, October 22nd nd 20112011

3 remarks3 remarks

1. Evidence based policy...from the Economics discipline perspective

2. Health and the economy3. Europe today: Competitiveness

and welfare state

Evidence based policyEvidence based policy

• Death penalty US 1975 re-established with biased evidence

• Practice makes perfect or referral effect?

• In search of causality– Experimental research– Natural experiments or quasi-experimental– Observational studies with longitudinal data

Health determinants rich countriesHealth determinants rich countries

• Nutrition and economic growth (mid XVIIIth century to mid XIXth century)

• Public Health (last decades XIXth century and first decades XXth century)

• Health Services (since 1940, 60, 80... it depends on countries)

Cutler D, Deaton A, Lleras-Muney A. The determinants of mortality. J Ec Perspectives 2006; 20(3): 97-120.

González B, Pinilla J. The impact of medical technology on health: A longitudinal analysis of ischemic heart disease. Value in Health 2008; 11(1): 88-96.

Crisis and welfareCrisis and welfare

• But ... makes sense to measure the success of countries by GDP growth?

Stiglitz J, Sen A, Fitoussi JP. Report by the Commission on the Measurement of Economic Performance and Social Progress. 14 Setembro 2009.

Welfare: many dimensionsWelfare: many dimensions

- Income, consumption and wealth- Health- Education- Personal activities, including work- Voice and influence in governance- Social connections and relationships- Environment (present and future conditions)- Insecurity - economic and physical

Effects of crisis in healthEffects of crisis in health

• Depend on the institutional context and the layering of civil society

• Welfare States- Basic pensions increase

reduces excess mortality in 'old‘- Policies aimed at lone parents

reduce child mortality • China’s great famine 1959-61

Unemployment rich Unemployment rich countriescountries

• Increases mortality (Brenner)

• Reduces mortality (Ruhm)

• Less tobacco consumption and weight loss• More physical activity during free time

Crisis in developing countriesCrisis in developing countries

• Very virulent in developing countries (Mexico 1996, SouthEast Asia 1997…)Impoverishment, unemployment, inflation, currency devaluation ...

• It affects the most vulnerable groups: children, elderly, poor, rural ... by way of loss of income and social security / health

• With reflections on various health indicators: infant mortality, low birth weight, incidence of diseases ...

RussiaRussia

• From 1990 to 1994• Standardized mortality increased by 30%,

particularly in men of working age (alcohol, malnutrition, external causes ...)

• Life expectancy for men dropped from 64 to 58 years (women, 74 to 71)

……RussiaRussia

• Gorbachev alcohol prohibition• Massive privatization:

Unemployment- Working age men increased mortality- Reduction in life expectancy- Social capital mitigates these effects

• Misreading of the fall of the Berlin Wall

FinlandFinland

• Severe recession in same years (1990 to 1994) than Russia: Unemployment 2 to 18%

- No adverse effects on health- On the contray, lower alcohol consumption

and reductions of socio-economics gradient in mortality

- Nordic welfare states

It seems that…It seems that…

• Not all economic crises are equal and have the same effects on health

• Public policy can prevent and cure many of the effects of the economic crisis on health

Strong institutions are key

Characterizing medical Characterizing medical systemssystems

(any is best in all dimensions)(any is best in all dimensions)

1. On average, medical spending is worth it David Cutler. Your money or your life

2. More spending is not always worth itElliott Fisher et al. Annals Internal Medicine 2003

3. Some care is underprovidedAdults in developed countries receive about half of needed medical care for the leading causes of death and disability

McGlynn et al. NEJM 2003; 348: 2635-45

Daily quality chasmsDaily quality chasms

• Hands washing• Surgical check list• Drug use• C-section

Sir Mike Richards: Extent and causes of international variations in drug usage. July 2010.

Avui mateix per Ricard Meneu

Enthoven A. NEJM 2011; e44

National Institute for Welfare National Institute for Welfare EnhancementEnhancement

• To avoid political shorsightness and achieve welfare state consolidation in a competitive economy

• Political agreement on procedures with democratic checks and balances on and independent body

• Intersectoral perspective and due account to intergenerational issues

González B, Ortún V. JECH 2010; 64:497-499

Quick remarks onQuick remarks on Economics and HealthEconomics and Health

Vicente OrtúnVicente OrtúnMadrid, October 22Madrid, October 22nd nd 20112011