BMJ

Budget crises, health, and social welfare programmes

Author(s): David Stuckler, Sanjay Basu and Martin McKee
Source: BMJ: British Medical Journal, Vol. 341, No. 7763 (10 July 2010), pp. 77-79
Published by: BMJ
Stable URL: http://www.jstor.org/stable/20734765
Accessed: 09-10-2015 17:36 UTC
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_ANALYSIS

Response on bmj.com
"Programmesmust... be designed to prevent furthernegative social problems,or financialrisk.The programmesmust
clearlybenefit the people of the country.There should be no partialityamong citizens,whether employed or unemployed."
Monique JGrant-Coke,nursingprogramcoordinatorand assistant professor,Jamaica
O To submita rapid response,go to any articleon bmj.comand select "Respond to thisarticle"

social

and

health,

crises,

Budget

welfare

programmes

Governments
health
mayfeeltheyareprotecting
bysafeguarding
healthcare
yetDavid Stuckler,Sanjay Basu,
budgets,
3
andMartinMcKee arguethatsocialwelfarespendingisas
ifnotmoreso,forpopulation
health
important
The recessionof2008 has had profoundeconomic
consequences

formany

countries. How

and when

was a major focusin the

toreducebudgetdeficits
recentgeneral election in theUnited Kingdom
and continues tomake headlines around the
world.

The new

government

has already

begun

thatpopulationhealth isnot onlydeterminedby

healthcare

expenditure

but by many

factors out

side the health system. The evidence, most

recently

reviewedindetailbyMichaelMarmot inhis report

on health inequalities,7
to theBritishgovernment
has highlightedhow investmentsina varietyof
who
socialpoliciesbenefithealth.Thus, children

1100

5 ? Hungary

1000

es,ovakia
fi
E Q.
- ? Poland
900
?
Czech
Republic
800.lre,and ?
Denmark
*
Portugal? United
Kingdom Finland
700
Luxembourg
Greece^ Irlands*
.?
fi
.? . ?
Germany
^
- Austna
A
*5

even
tomake largecuts inpublic expenditure,12
receive better education, have safe environments in
thoughtheUK's projectedunderlyingdebt, as a
1000
2000
4000
3000
5000
6000
shareofgrossdomesticproduct(GDP),is less than which toplay,andwho liveingood qualityhous
Social
more
are
to
than
it
has
those
per
power
thatofotherindustrialised
spending
capita
(purchasing
parity)
countries,
longer ing
likely growup healthy
thanmany othercountriesbeforeitis requiredto who do not. Adults in secure and safe employment,
Fig 11 Relation between social welfare spending and
refinanceloans (table1), and theactual deficitin receiving
wages above thelevelneededmerely to all cause mortality in 18 EU countries, 2000
are less likelytoadopthazardous lifestyles
less than expected.
2009-10 was considerably
survive,
orunhealthy
15 European Union countries forwhich compara
diets)and
drinking,
Leading economistshavewidely divergentviews (suchas smoking,
tivedata are available over thepast threedecades
aboutwhetherthecutswill aid orhindereconomic can expect to live longer.
4
of
this
evidence
for
the
to
Yet
the
wel
scant
the
attention
but
have
(Austria, Belgium,
Denmark,
France,
Finland,
implications
paid
recovery,3
of reductionsinhealthand social farestateare contested.Do theyimplytheneed for Germany, Greece, Ireland, Italy, Luxembourg, Neth
potentialeffects
a well functioning
on population
welfare statethatcan support erlands,Portugal,Spain, Sweden, and theUnited
health.5 We examine
expenditure
historicaldata forinsightsintohow lowerlevels people at all stagesof theirlives,activelyseeking Kingdom).10This covers 1980-2005, although
topromote
health.
ofpublic spendingmightaffect
wellbeing forall?Or is thewelfarestate mortalitydata forBelgiumwere available up to
out individualinitiative onlyl998.n
of
the
part
problem,driving
toproducea cultureofdependency
as
TheOECD definessocialwelfareexpenditure
and creativity
Wider view offhealth spending
What little
discussion therehas been abouthealth thatstiflestheemergenceofan improvedsociety? "theprovisionbypublic (andprivate)institutions
viewshave led toa politicaldebate ofbenefitsto,and financialcontributions
Thesedivergent
in the current economic
recession has focused
targeted
onwhether toringfenceNHS spending.6This isa
characterised
at,households and individualsinordertoprovide
by, on the one hand, calls for ever
narrow perspective
supportduring circumstanceswhich adversely
greater "efficiency savings,"8 which is increasingly
given the extensive evidence

seen as a euphemism

Table 11Summary of deficit, debt, and debt

repayment inselected countries1

Country

Deficitas
% ofGDP

Gross debt
as a % of
GDP

Germany
US

-5.7_7215_6S)_
-11.0
83.2

France

-8.2

77.4

UK

-11.4

68.2~

Greece
Japan
Italy_-5.2
Portugal

-8.1_115.1
-9.8

cuts, and, on the

in the context of losses of income, increased unem

ployment,

and overall economic

insecurity.9

affect their welfare."10

6.5_
12.8_
7.4_
_5.2
6.7
_

_6J_

GDP=gross domestic product.

This

includes

spending

related to familysupportprogrammes (such as

preschool

education,

child care, and maternity

or

paternityleave),old age pensions and survivors

benefits, health

care, housing

dies), unemployment

217.7

2010 |VOLUME 341

BMJ 110JULY

Average maturity
ofgovernment
debt (years)
4.4

115.8
-8.8_77

forbudget

to pro
other, calls for "stronger social safety nets...
tect themost vulnerable in rich and poor countries"

(such as rent subsi

benefits, active labour market

orhelp the
What do the data show?
programmes(tomaintainemployment
One way to informthisdebate is to examine unemployedobtain jobs),and supportforpeople
All of thesecould plausibly
whether thereisa historicalassociationbetween with disabilities.71213
levelsof social spendingand population health affecthealth.Although theOECD has developed
data on social welfare
outcomes. We evaluated
standardiseddefinitions
and harmoniseddata col
across countries,
the
for
Eco
collected
lection to ensure comparability
Organisation
by
spending
nomic Cooperationand Development (OECD),10 we adjusted thedata furtherto takeaccount of
with age standardisedall cause mortalityin the purchasingpowerparityand inflation.Figure 1

77

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ANALYSIS_

Table 31 Effect of $100 of income, social welfare spending, and healthcare spending on cause specific
(purchasing power parity in$ for2000)
mortality in 15 EU countries, 1980-2005

-4000

4000

2000

-2000

Deviationfrom
averagespendingon socialwelfarepercapita
country
Fig 21 Relation between deviation fromcountry

health)
averageofsocialwelfarespending(excluding
and all cause mortality in15 EU countries,1980-2005.
Each point represents a single country year value.

Social welfare spending is inconstant US dollars (year

powerparity
2000) adjustedforpurchasing

Alcohol
related

Malignant
neoplasms

-0.21%

-0.034%

All cause

Covariate

Cardiovascular
disease

Suicide

Tuberculosis

$100 in incomepercepita

-0.14%**
(0.035)

(0.12)

(0.034)

(0.084)

(0.20)

(0.14)

$100 rise insocial welfare

spending (excludinghealth care)

-0.99%***

-2.80%***

-0.065%

-1.23%**

-0.62%

-4.34%**

(0.11)

(0.46)

(0.18)

(0.31)

(0.49)

(1.27)

$100 rise inhealthcare spending

-0.01%

0.97%

-0.82%

-0.28%

-3.15%

2.11%

(0.43)

(0.90)

(0.47)

(0.95)

(1.50)

(2.32)

No of country-years

320

319

319

0.773

0.535

0.239

0.716

R2
0.906

-0.31%**

0.19%

-0.59%***

319

319
318

0.901

Countrieswere Austria,Belgium,Denmark, Finland,France,Germany,Greece, Ireland,Italy,Luxembourg,Netherlands,

Portugal,Spain, Sweden, and United Kingdom.Robust standard errors inparentheses clustered by countries to reflectnon
independence of sampling.

of thana similarmagnitude rise inGDP (0.80%

protecttheNHS at theexpense ofotherservices,

a keyquestion iswhethertheassociationbetween
spending
forsocialwelfarespending,theassociationofGDP socialwelfare spendingandmortality isdriven
tries (r=-0.78, P<0.001).
However,toquantifythisrelation,itisnecessary with lowermortalitywas cutby about two thirds by expenditureson health care or by the social
to lookat resultsovertimeand to takeaccount of (from0.28% to0.11%, table2). Thismeans that spending programmes. Table 3 shows that social
thepotentialhealthbenefitsof increasedwealth
otherfactorsthat
spending was significantly associated with mor
mightexplainthisapparentasso
on
not
income
but
related to social circumstances
ciation, such as remaining differences in categoris
increasing
just
depend
crucially
tality from diseases
inmortality. onwhat fractiongoes intosocialwelfarespending (such as alcohol relateddeaths) but healthcare
differences
ingspendingorunderlying
differences from governments.
in
We therefore
increases
correctedforfixedcountry
spending was not. Thus although
shows

a clear association

between

in 2000

and mortality

social welfare

across

EU coun

0.11%,

table 2. Furthermore, when we adjusted

social welfare
overall are associated
spending
dummyvariables),reporting
(byincludingcountry
with reducedmortality fromthese conditions,
betweensocial Comparing social spending with healthcare
estimatesof thelongtermrelations
Given spending
theeffectisdue tospendingon areas other than
spendingand healthwithin each country.
health. Futureresearchshould lookat theeffect
ofdifferencesinsocial We recognise that correlation may not mean
thatthetiming
of theeffect
ofdifferent
typesof social spending(employment
spendingisuncertain,themethodwe used enabled causation; we also need to consider multicolin
us toaccount foranypotential laggedeffects(up earity(multiplevariables thathappen tochange versus housing for example). For now, this result
mean countryspecific together)and thepotential forundetected con
indicatesthatsome aspects ofpopulationhealth
toa decade) by estimating
our
are
more sensitive, in the short term, to spending
to
constrains
isolate
the
to
that
health.14
social
Figure founding
ability
spending
slopes relating
on
on
welfare
health.
in
of
each
social
social support thanon health care,although
effects
which
in
each
2,
country
spending public
point represents
Oneway toscreenforthisproblem isby compar a caveat is necessary as these countries have not
each year, shows a clear association between social
would not experienced changes inhealthcare fundingof
welfare spending and all cause mortalityafter ingmortalityfromcauseswhere there
adjustmentforany countryspecificfactors.Ifno plausiblybe a shorttermrelationbetweenhealth thescale thatmightbe expected toaffecthealth.
the maintenance
of social welfare
Nevertheless,
countrydeviated fromtheaverage socialwelfare and social spending, such as most cancers, with
we
zero.
a
diseases
where
would
seems
from
at
to
be
of
would
cluster
all
expect programmes
mortality
key determinant
points
spending,
to see changeswith spending, such as alcohol
be
future
health
that
should
taken
into
Themodels constructedshow thateach addi
population
account in ongoing economic debates.
tional$100 increase in socialwelfare spending relateddeaths. Our findingsare in linewith pre
has been associatedwitha 1.19% drop inall cause dictions(table3) supportingtheidea thatourfind
were spe
ourfindings
Implicationsforpublic health practice
ingsare not simplydue tomulticolinearity.
mortality(table2). Crucially,
In thecurrentdebate on spending cuts in the The delivery of public services in the UK is
cifictosocialwelfarespending(as definedabove);
there was no observable
UK, inwhich some politicianshave promised to recognised to be impeded by pervasive silo
protective effect associ
is
which
atedwith generalgovernment
spending,
understandable

since military, prison,

or similar

spendingwould notbe expected tohave a visible

publichealtheffect.
Clearly,it is importantto takeaccount of the
will spendmore,
probabilitythatrichercountries
which

could produce

an artefactual

association

Table 21 Effect of $100 of income, social welfare, and general government spending on all cause mortality for

15 EUcountries,
1980-2005(purchasing
powerparityin$ for2000)
Social welfare
Covariate
spending
$100 rise insocial welfare
spending (includinghealth care)

betweengoodhealth (asa resultof relative

wealth)
in incomepercapita
and overallhighersocialwelfare spending.As in $100
$100 rise ingeneral government
was
we
previousresearch, foundthathigherGDP
spending (excludingsocial
indeed associated with lowermortality (each welfare spending)
associ
No of country-years
$100 increase inGDP was significantly
atedwith a 0.11% fallinall causemortality).1516
However,

we

also

found

that a comparable

rise

in socialwelfare spendingwas associated with

over a sevenfold

greater

reduction

inmortality

-1.19%* (0.068)
-

320
R2
0.865

_Statisticalmodel_
Incomeand general
governmentspending
-0.80%*
(0.098)

Income

-0.28%*
- -0.27%

(0.041)

-0.24%* (0.050)
(0.15)

Social welfare spending

and income

-0.11%* (0.025)

258
320
320
0.792

0.787
0.900

Countrieswere Austria,Belgium,Denmark, Finland,France,Germany,Greece, Ireland,Italy,Luxembourg,Netherlands,

Portugal,Spain, Sweden, and United Kingdom.Robust standard errors inparentheses clusteredby countriesto reflectnon
independence of sampling.
*P<0.001.

78

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2010 |VOLUME 341

BMJ 110JULY

_ANALYSIS

mentalities, with interagency collaboration

hampered by poor communication and differ
to
ent styles of operation.17
Previous
attempts
overcome
such as the creation
these problems,

ofhealth action zones, have had littlesuccess.18

In some

of this fail

the consequences

cases,

ure are highlyvisible, such as thehigh profile

deaths ofyoung childrenat thehands of their
carers where

were missed

problems

between

poor communication

because

several

of

agencies.

More often,however,theproblemsgo unnoticed,

exceptby thosepeople who struggleas theygo
fromagency toagency, seeking an integrated
assistance

needs.

for complex

package

There

is

a realdanger thatspending cuts could accentu

ate

this problem,

each

encouraging

organisa

tion tobehave opportunistically, transferring

as much responsibilityforcomplexproblems to
others,

and

only on the narrow

concentrating

targetstheycan use most easily to justifytheir

existence.19
some

Yet there are also

action.

One

Place

for

considerable

attracting

example

is the Total

attention

avenues

positive

programme,

together.

count

three elements:

Ithas

ing (trackingfinancial flows to agencies and

ways inwhich money can be spent
identifying
most effectively),
whether
culture (determining
or
service
hinder
cultures
organisational
help
delivery,and how to facilitate their improve
ment), and customerneeds (placing thecentral
focus on service

involved

The agencies

users).

in each scheme vary,butmany include local

government,
authorities,
and
have

care trusts, police

primary

and welfare

employment

regional
also

included

and fire
agencies,
Some

organisations.

development

the non-governmental

sec

tor.The pilots are currently

being evaluated by
researchersfromtheUniversityofBirmingham,
but theyhave alreadyprovidedmany examples
of how

government

institutional
smaller

local

agencies

boundaries.20
initiatives

can work

across

across

sectors,

awards.21

Correspondence to: D Stuckler

David.stuckler@chch.ox.ac.uk
Accepted: 27 May 2010
Contributorsand sources: DS, SB, and MMcK have published
extensivelyon thedeterminantsof health insocieties

The ideacame out

undergoingsocial and economic transition.
of discussions among DS, SB, and MMcK. DS did the analyses
and draftedthe paper,which SB andMMcK revised.

Competing interests:None declared

Provenance and peer review: Not commissioned; externally
nppr rpvipwpd
1
2

3
4
5
6

7
8

12

13

14

15

17

18

difficulties

could be viewed as an opportunitytoreorganise

provisionof services to those inneed, creating
a broader setof services thatreflectthe increas
inglycomplex needs of a society facinghealth
challenges as varied as fastfoodand dementia.
were
Itwould be unfortunateifthisopportunity
wasted. Ifthe firstpriorityof a government is
toprotect the lives of itspeople, a statement

International
MonetaryFund.Fiscalmonitor. IMF,2010.
StucklerD, Basu, S, McKee, M, Suhrcke,M. Responding
to theeconomic crisis:a primerforpublic health
professionals./Pu?Health (forthcoming).
Eaglesham J,Pimlott,D. Economists rejectcalls forbudget
cuts.FinancialTimes 2010 February18.
Giles C, Pimlott,D, Eaglesham,]. UKdeficitwarning from
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Cityeconomists. FinancialTimes 2010 January
StucklerD, Basu, S, McKee, M. How governmentspending
cuts put livesat risk.Nature 2010;465:289.
Crawford,
R, Emmerson,C. How coldwill itbe?
Appleby J,
Prospects forNHS funding:2011-2017. London:King's
Fund,2009.
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College
London,2010.
PorterA. Business leadershitback at 'patronising'Labour
claims on ToryNI plan.Daily Telegraph2010 Apr 1.

www.telegraph.co.uk/news/election-2010/7543905/
Business-leaders-hit-back-at-patronising-Labour-claims
on-Tory-NI-plan.html.
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levelconsultation.WHO, 2009.
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Development social expendituredata. OECD, 2008.
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SirMichael Marmot's recentreviewon health

current economic

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Medicine, San FranciscoGeneral Hospital

MartinMcKee professorof European public health,European
Centreon Health of Societies inTransition,London School of
Hygiene and TropicalMedicine

inequalities in theUnited Kingdom concluded

in
that"Austerity
need not lead to retrenchment
thewelfare state. Indeed, theoppositemay be
The

it should

David Stuckler researcher,DepartmentofSociology,Oxford

Oxford,
University,
Department of Public Health and Policy,London School of
Hygieneand TropicalMedicine, LondonWC1E 7HT
Sanjay Basu physician,DepartmentofMedicine, University
of CaliforniaSan Franciscoand DivisionofGeneral Internal

16

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then

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that work

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of the implicationsof itseconomic policies for

now

involving13 communitiesacross England.20This

seeks todevelopnewways thatdifferent
agencies
can work

oftenmade in response to theperceived threat

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20
21
22

http://data.euro.who.int/hfadb/.
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Cite thisas: BMJ2010;340:c3311

Is chronic
kidneydisease
bad medicine?
This week we publish several

letters in response

toa recent
BMJcolumnarguingthatchronic
disease (CKD)isa condition
witha
kidney

poor evidence base which has unnecessarily

medicalised10% ofthepopulation.
Meanwhile,
discussionisthrivingon
doc2doc,BMJ
Group's
global online clinical community.

PieterKubben:"Manythingsfor
whichwe
used to say 'We don't know what

it is, so you'll
have to livewith it,'now require a 'label'
Industry interestmay be both a cause and a

consequence.
Attention-deficit/hyperactivity
disorder is another good example."
Tauseef Mehrali:

"Recently, I've had two

encounters
withpatientsfumingthat
nobody
toldthemtheyhad stagetwokidney
disease

(after seeing the classification on theiraccident

and emergency discharge summaries). They'd
created dialysis based nightmarish visions

forthemselves.
What's thefirst
of
thingIthink
when Ithink'renal
medicine'?Anotherspecialty
adulterated

by the creation of pre-diseases."

Carlos Cuello: "In paediatrics, our tutors taught

us that patients with urinary tract infections

willeventually
getCKD iftheyarenotgiven
orsubjectedtoexpensive
antibiotics
lifelong
studiessuggestthisis
monitoring.
Onlyrecent
not true."

Dr AGS: "Iwould

like to 'un-diagnose'

all people

overtheage of70witha estimatedglomerular

filtration rate of 45 or more. Most

ridiculous of

all istheeffect
incookedmeat has
Creatinine
on the estimated glomerularfiltration

rate.My

has had a handful

ofCKD3patients
surgery
'cured' after not eating meat fora few hours."

yoram charter: "It is not mere

labelling; it is a
condition that affects many future treatment

decisions

of differentmedical

conditions."

French GP: "When you referto a nephrologist,

the patient comes back with fear, anxiety, and

a number of pendingtests.

Moreover,

nephrologist has changed

treatment and you

the

have todealwithhigher
bloodpressure,higher
glycated hemoglobin,
high as before."

and serum Creatinine as

atbeat:"Iam a nephrologist
butmyopinion

about CKD causing increased anxiety and costs

appears to fallon deaf ears."
csm@csm:

"CKD isa failed experiment, a

and just

mockery of evidence based medicine,

more bad modern medicine."

"I rejecttheideaofCKDbeing
M.B.Ibrahim:
is scarce

bad medicine.True

evidence

branch ofmedicine

not only nephrology."

Where do you stand on the issue of CKD?

O Have your say at http://bit.ly/9lbuMU

341 79
BMJ
110JULY
20101VOLUME

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inevery