Dissertation committee:
Ιωάννης Υφαντόπουλος, Ομότιμος Καθηγητής, Τμήμα Πολιτικής Επιστήμης και Δημόσιας Διοίκησης, Εθνικό και Καποδιστριακό Πανεπιστήμιο Αθηνών
Αντώνιος Μακρυδημήτρης, Καθηγητής, Τμήμα Πολιτικής Επιστήμης και Δημόσιας Διοίκησης, Εθνικό και Καποδιστριακό Πανεπιστήμιο Αθηνών
Μαρία Γείτονα - Κοντούλη, Καθηγήτρια, Τμήμα Κοινωνικής και Εκπαιδευτικής Πολιτικής, Πανεπιστήμιο Πελοποννήσου
Ναπολέων Μαραβέγιας, Καθηγητής, Τμήμα Πολιτικής Επιστήμης και Δημόσιας Διοίκησης, Εθνικό και Καποδιστριακό Πανεπιστήμιο Αθηνών
Γεώργιος Πιερράκος, Καθηγητής, Τμήμα Διοίκησης Επιχειρήσεων, Πανεπιστήμιο Δυτικής Αττικής
Μαρία - Ηλιάνα Πραβίτα, Επικούρη Καθηγήτρια, Τμήμα Πολιτικής Επιστήμης και Δημόσιας Διοίκησης, Εθνικό και Καποδιστριακό Πανεπιστήμιο Αθηνών
Νικόλαος - Κομνηνός Χλέπας , Καθηγητής, Τμήμα Πολιτικής Επιστήμης και Δημόσιας Διοίκησης, Εθνικό και Καποδιστριακό Πανεπιστήμιο Αθηνών
Summary:
Introduction: Although many studies have documented the detrimental health impact of the economic crisis in Greece, the relevant changes in the pattern of health inequalities have not been investigated to the same degree. Purpose and objectives: The primary purpose of this dissertation was to assess the impact of the economic crisis on socioeconomic inequalities in health status in Greece, and, in particular, to investigate: 1) the evolution of socio-economic health inequalities, 2) the determinants of socioeconomic health inequalities and 3) the determinants of changes in socioeconomic health inequalities. Methodology: The research approach of the dissertation was interdisciplinary. More specifically, the thesis began its research journey from the field of a) ethics and political philosophy to investigate the application of theories of justice in the domain of health, it continued with the discipline of b) social epidemiology and the examination of the mechanisms linking health status with the crisis and concluded with the assessment of the evolution of socioeconomic health inequalities and their factors through the scientific field of c) health economics. For the empirical part, the microdata of the databases of the EU-SILC surveys in Greece for the period 2003-2017, i.e. data for a total of 281,514 individuals and their households, were employed. Multiple health outcomes, socioeconomic variables and health inequality indicators were used to analyze the evolution of health inequalities. The determinants of changes in income-related and education-related health inequalities were investigated with an Oaxaca type decomposition analysis of the respective concentration indicators separately for the periods 2005-2008, 2008-2012 and 2012-2015. As for the independent factors, a wide range of variables was used, which affect health in different ways and at different levels of analysis. Results Theories of social justice in health: A comprehensive conceptual framework was constructed for the classification of theories of justice in health with respect to the judgement of health distributions and the field of health economics. A central choice was the separation of the currency of justice (e.g. health status, opportunities or capabilities for health) from the distributive principles (e.g. egalitarianism, maximization). These theories are required to justify the need of adopting policies to mitigate or eliminate health inequalities defined as inequities, while they also define the normative criteria for choosing between alternative policy scenarios. Economic crisis and socioeconomic health inequalities: The examination of the theories and mechanisms of socioeconomic health inequalities led to the construction of a unified model describing the mechanisms through which the economic crisis affects health and its distribution in the population. More generally, the health impact of the crisis can be attributed to: a) the recession and b) the austerity measures. The central choice of this model was to separate the mechanisms found in the broader (macro- and mid-) level, such as the curtailment of social protection, from those that operate at the individual (micro-) level, such as the job loss. These socioeconomic changes and experiences influence through some intermediate mechanisms, such as the distribution of time, specific immediate risk and resilience factors, which in turn affect individuals' health in a differentiated way. Each mechanism encompasses multiple causal linkages between socioeconomic changes and individual health, which may have positive or negative health effects, depending on some social and biological factors that modify the relevant causal routes. Health inequalities indicators: A review of the methods for the measurement of health inequalities demonstrated that the choice of the inequality index implies the acceptance of specific implicit or explicit value judgements, which influence our conclusions regarding the magnitude of the inequality and the ordering of health distributions. It is also interesting that the normative issues are quite intertwined with the methodological ones during the measurement process. Evolution of health inequalities: The evolution of the standardized by sex and age health distributions showed that there was trend of either an independent deterioration or an intensification of the preexisting deterioration rate of the average population health, especially in the period 2012-2014. In addition, total health inequalities, both absolute and relative, mostly widened during the crisis, especially between 2012 and 2014, while they appear to deescalate after 2015. During the overall period of the crisis, although large fluctuations were observed, most socioeconomic health inequalities decreased, especially the economic-related ones in the years of the deep recession. Exceptions were found with respect to gender, degree of urbanization, education, environmental problems and severe housing deprivation, which are variables inelastic to the effect of downward socioeconomic mobility. Finally, socioeconomic health inequalities tend to decrease for all health outcomes after 2015. Determinants of socioeconomic health inequalities: Overall, significant heterogeneity was found in the results for the socioeconomic health inequalities due to the different health outcomes and socioeconomic classification variables that were used. However, the presence of consistent and statistically significant socioeconomic health inequalities was established. Income-related health inequalities were decreasing during the period of the deep recession, extending the preexisting trend, while in the second period of the crisis they were increasing. In contrast, education-related health inequalities were widening in all three periods of the analysis, especially in the last one. Consistently important factors in generating income-related health inequalities were (in order of magnitude): education, severe material deprivation, income and employment status. Furthermore, age increased income-related health inequalities in the period of 2005-2008, while it contributed to their reduction during the crisis. Also, low household work intensity and severe housing deprivation led to the increase of inequalities and citizenship, region of residence and population density to their decrease, but only during the crisis and especially in 2012. On the other hand, education, age and employment status were the most important factors generating education-related health inequalities. Determinants of changes in socioeconomic health inequalities: The determinants of socioeconomic health inequalities are not identical with those of their changes during the crisis, as in the second case we are interested in the changes in the elasticity of health or the unequal distribution of each variable. The decomposition analysis revealed the concurrent operation of multiple mechanisms that affect the changes of socioeconomic health inequalities in opposite ways. To start with, a significant economic re-ranking and downward social mobility during the crisis led to changes in the composition of some populations and the narrowing of income-related health inequalities. In particular, the economic impact of the crisis was greater for those whose income was exposed to market fluctuations than for those who relied mostly on social transfers. As a result, some groups of people with more health problems, such as the elderly, the pensioners and the disabled, improved their relative position in the income distribution. In addition, negative socioeconomic changes, such as job loss and income reduction, led to downward social mobility of people with fewer health problems than those in the socioeconomic category in which they ended up, thereby improving the average health level of this lower category. Although the education distribution is less flexible to changes than the income one, the socioeconomic mobility during the crisis affected the composition of some populations with respect to their level of education as well. Also, there were some changes in the marginal health effect of some factors, which affected the changes in education-related health inequalities in particular. Finally, some results indicated the parallel operation of the ceiling/floor mechanism, as in some cases a greater health deterioration was found in the upper end of the socioeconomic distribution than in the middle parts. Overall, during the period of deep recession, employment status, income, age and region of residence contributed to the mitigation and severe material deprivation and low work intensity to the aggravation of income-related inequalities. For the same period, income, employment status and region of residence contributed to the reduction and education, age, marital status and pollution problems to the increase of education-related health inequalities. During the second period of the crisis, low work intensity, employment status, age, severe housing deprivation and pollution problems led to the decrease and income, citizenship, severe material deprivation, region of residence and population density to the widening of income-related health inequalities. For the same period, pollution problems reduced and employment status, education, age, marital status, income and region of residence exacerbated education-related health inequalities. Conclusions - Policy implications: In conclusion, there is an important interdependence between the ethical and the empirical dimensions in the research of socioeconomic health inequalities, which affects both the measurement process and the interpretation of its results as well as policy implications. Addressing socioeconomic health inequalities in Greece requires an interdisciplinary approach and a national health strategy breaking down the traditional government “silos” and promoting intersectoral collaboration between the different lines of administrative accountability. Furthermore, social protection policies are crucial not only for protecting the population from the health effects of the crisis, but also for curbing socioeconomic health inequalities. Lastly, policies targeting specifically the most vulnerable population groups are essential, especially for those individuals with severe or multiple social disadvantages, such as those in extreme poverty or/and with a low level of education and training.
