Economic Recession and
Health: the Case of Greece
Dr. Filippos Filippidis
School of Public Health
Imperial College London 1
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
2
Background I
3
Background I
4
Background II
5
Background III
Population (millions) 10.8 63.2
GDP per capita ($ PPP) 25,331 37,299
Gini index 33.5 33.0
Human Development Index 0.860 0.875
Life expectancy (years) 80.3 80.4
Infant mortality (per 1,000 live births) 3.1 4.6
Health expenditure (% of GDP, 2009) 9.6 9.8
Expenditure on pharmaceuticals (% of GDP, 2009) 2.4 1.0
Practising doctors (per 1,000 population) 6.1 2.7
Practising nurses (per 1,000 population) 3.3 9.7
6
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
7
GDP per capita, Greece
0
5000
10000
15000
20000
25000
2006 2007 2008 2009 2010 2011 2012
GD
P p
er
ca
pit
a (€)
Year
8 Eurostat 2013
Wages and Consumer Prices in
Greece (2009=100)
0
20
40
60
80
100
120
2006 2007 2008 2009 2010 2011 2012 2013
Ind
ex
(2
00
9=
10
0)
Year
Wage index Consumer Price Index
9 Hellenic Statistical Authority 2013
Unemployment in Greece
0
5
10
15
20
25
30
2006 2007 2008 2009 2010 2011 2012 2013
Un
em
plo
ym
en
t %
Year
10 Hellenic Statistical Authority 2013
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
11
Effects of economic crises on
health
• Decline in tobacco use
• Decline in road traffic accidents
• Decline in mean alcohol consumption –
increase among the unemployed
• Increased impact of communicable diseases
• Increase in suicides
• Variable effects on all-cause mortality
• Greater impact in vulnerable groups
12
13
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
14
Self-reported health, 2006-2011
15 Zavras et al. EJPH 2012
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
16
Self-reported mental health I
61% 58%
67%
43% 46%
57%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Happy Calm and peaceful Full of life
% o
f p
op
ula
tio
n w
ho
re
plie
d “
all
or
mo
st o
f th
e tim
e”
2006 2010
17 Eurobarometer 2006, 2010 * Past 4 weeks
Self-reported mental health II
70% 66%
52% 56%
51%
43%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Down in the dumps Downhearted & depressed Worn out
% o
f p
op
ula
tio
n w
ho
re
plie
d “
ne
ve
r o
r ra
rely
”
2006 2010
18 Eurobarometer 2006, 2010 * Past 4 weeks
Depression
2.4%
4.6%
6.7%
3.8%
8.8%
9.9%
0%
2%
4%
6%
8%
10%
12%
2008 2009 2011
1-m
on
th p
reva
len
ce
of m
ajo
r d
ep
ressio
n
Year
Males Females
19 Madianos et al. Soc Psychiatry Psychiatr Epidemiol 2011
Economou et al. J Affect Disord 2013
Suicide in OECD countries (2008)
20
OECD, Health at a Glance Europe 2010
Suicides and homicide in Greece
21
0
1
2
3
4
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Mo
rta
lity
pe
r 1
00
,00
0
Year
Suicides and self-inflicted injury 0-64 Homicide and intentional injury 0-64
Fountoulakis et al. Eur Arch Psychiatry Clin Neurosci 2012
Hellenic Statistical Authority
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
22
Infectious diseases
• West Nile virus outbreak
(2010 – 197 cases/35 deaths)
• Malaria outbreak in southern Greece
(2011 – 60 cases)
• Newly diagnosed HIV-1 infections
(57.2% increase from 2010 to 2011)
23 Bonovas et al, J Prev Med Hyg, 2012
Infectious diseases in Greece
24
0
2
4
6
8
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Sta
nd
ard
ise
d m
ort
ali
ty p
er
10
0,0
00
Year
WHO Health for All Database 2013
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
25
Transportation costs
0
20
40
60
80
100
120
140
160
180
200
2006 2007 2008 2009 2010 2011 2012 2013
Price
Co
nsu
me
r In
de
x
Year
Price Consumer Index Fuel Road taxes - tolls Public transportation
26 Hellenic Statistical Authority 2013
Car sales in Greece
27
0
100,000
200,000
300,000
400,000
500,000
600,000
2006 2007 2008 2009 2010 2011 2012
Nu
mb
er
of
Ve
hic
les
Year
Hellenic Statistical Authority 2013
Transport accidents in Greece
28
0
5
10
15
20
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Sta
nd
ard
ise
d m
ort
ali
ty p
er
10
0,0
00
Year
WHO Health for All Database 2013
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
29
Levels of Physical Activity in Greece I
34.5% 28.4%
41.8% 29.6%
43.9%
29.5%
43.5%
42.6%
38.3%
38.6%
31.5%
36.8%
22.1% 28.9%
19.8% 31.8%
24.6% 33.7%
0%
20%
40%
60%
80%
100%
2006 2011 2006 2011 2006 2011
Socio-economic status
Low Middle High
Higher SES Middle SES Lower SES
30 Physical activity levels according to IPAQ Filippidis et al (under review)
Levels of Physical Activity in Greece I
31
0
2000
4000
6000
8000
To
tal M
ET
-min
/we
ek
Higher Middle Lower
2006 2011 2006 2011 2006 2011
Socioeconomic status
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
32
Obesity in OECD countries (2008)
33 OECD, Health at a Glance Europe 2010
Overweight and obesity in Greece
39.6%
40.7%
41.4%
42.3%
40.3%
40.2%
18.2%
18.9%
18.4%
0% 20% 40% 60% 80% 100%
2011
2008
2006
Ye
ar
Normal weight Overweight Obese
34 Filippidis et al (under review)
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
35
Smoking in OECD countries (2008)
36 OECD, Health at a Glance Europe 2010
Tobacco control measures
• Partial smoking ban in public places (July
2009)
• Comprehensive smoking ban (July 2011)
• Tobacco tax increases
• Weak enforcement
37
Secondhand smoke in Greece
38 Vardavas et al. J Aerosol Med Pulm Drug Deliv 2012
Tobacco prices
60
70
80
90
100
110
120
130
140
2006 2007 2008 2009 2010 2011 2012 2013
Price
Co
nsu
me
r In
de
x
Year
Tobacco Price Consumer Index
39 Hellenic Statistical Authority 2013
Prevalence of smoking in Greece I
52.4%
48.5% 45.7%
34.5% 37.1%
31.1%
43.1% 42.6%
38.1%
0%
10%
20%
30%
40%
50%
60%
2006 2008 2011
Year
Males Females Total
40 Filippidis et al (under review)
Prevalence of smoking in Greece II
48.8% 48.9%
39.7%
44.4% 44.0% 43.9%
38.9% 35.9%
29.5%
0%
10%
20%
30%
40%
50%
60%
2006 2008 2011
Year
Higher SES Middle SES Lower SES
41 Filippidis et al (under review)
Intention to quit smoking in Greece
42 Schoretsaniti et al. Addict Beh 2013
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
43
Prices of fruits & vegetables
60
70
80
90
100
110
120
2006 2007 2008 2009 2010 2011 2012 2013
Price
Co
nsu
me
r In
de
x
Year
Food Vegetables Fruit
44 Hellenic Statistical Authority 2013
Consumption of at least 5 portions of fruit
& vegetables per day
8.0%
9.8% 9.0% 8.4% 8.9%
4.1%
0%
2%
4%
6%
8%
10%
12%
Higher SES Middle SES Lower SES
Socio-economic status
2008 2011
45 Filippidis et al (under review)
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
46
Health expenditure (PPP$ per capita)
0
500
1000
1500
2000
2500
3000
3500
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Ex
pe
nd
itu
re P
PP
$ p
er
ca
pit
a
Year
Pharmaceuticals Other
47 WHO Health for All database 2013
Households’ health expenditures
48 Kondilis et al. Am J Public Health 2013
Health services
• 59% of the population had to reduce the
use of health services between 2011 and
2012 because of high costs and/or
accessibility issues
• Increased numbers of outpatients and
inpatients in public hospitals
• Unavailability of pharmaceuticals
• Disruptions in healthcare market
49 National School of Public Health 2012
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
50
Infant mortality in Greece
51
0
2
4
6
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Sta
nd
ard
ise
d m
ort
ali
ty p
er
10
0,0
00
Year
WHO Health for All Database 2013
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
52
Causes of death in Greece, 2010
53 Institute for Health Metrics and Evaluation 2013
Causes of DALYs in Greece, 2010
54 Institute for Health Metrics and Evaluation 2013
All-cause mortality
55
0
100
200
300
400
500
600
700
800
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Mo
rta
lity
pe
r 1
00
,00
0
Year
Greece United Kingdom European Union
WHO Health for All Database 2013
Outline • Background
• Economic recession in Greece
• Economic recession and health – overview
• Health indices in Greece – Self-reported health
– Mental health
– Infectious diseases
– Traffic accidents
– Physical activity
– Obesity
– Smoking
– Diet
– Health services
– Infant mortality
– All-cause mortality
• Conclusions
56
Conclusions
• Decline in road traffic accidents
• Increase in physical activity levels
• Decrease in tobacco use
• Deterioration of mental health
• No evident short-term effects on all-cause
mortality
• Indications of widening inequalities
57
Long-term effects
58