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Health Policy 103 (2011) 168175

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Health Policy
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Economic crisis and communicable disease control in Europe:


A scoping study among national experts
Boika Rechel a , Marc Suhrcke a , Svetla Tsolova b , Jonathan E. Suk b , Monica Desai c ,
Martin McKee c , David Stuckler c,d , Ibrahim Abubakar a , Paul Hunter a , Michaela Senek a ,
Jan C. Semenza b,
a
b
c
d

Norwich Medical School, University of East Anglia, Norwich, United Kingdom


Future Threats and Determinants Section, Scientic Advice Unit, European Centre for Disease Prevention and Control, Stockholm, Sweden
London School of Hygiene and Tropical Medicine, United Kingdom
Department of Sociology, University of Cambridge, United Kingdom

a r t i c l e

i n f o

Keywords:
Communicable diseases
Communicable disease control
European Union
Economic crisis

a b s t r a c t
Objectives: The effects of the current global economic crisis on the spread and control of
communicable diseases remain uncertain. This study aimed to explore experts views about
the impact of the current crisis and measures that have been undertaken by governments
to mitigate an alleged adverse effect of the crisis on communicable diseases.
Methods: An online survey was conducted during November 2009February 2010 among
experts from national agencies for communicable disease control from European Union
(EU) and European Free Trade Association (EFTA) countries.
Results: There were few specic national policies and programmes aimed at mitigating the
impact of the economic crisis. Prevention services were deemed particularly susceptible to
budget cuts (68%) as a result of the economic crisis compared to primary care (28%), according to survey respondents. Services targeted at vulnerable and hard-to-reach population
groups were perceived to be at particular risk of deterioration (67%) in contrast to travel
medicine (11%), according to respondents.
Conclusions: There is a need for sustainability of nancial resources, public health workforce
and infrastructures to ensure that the services and programmes for the surveillance and
control of the spread of communicable disease are maintained and developed. There is also
a need to explore and foster better linkage in data on socioeconomic circumstances and
communicable disease outcomes.
2011 Elsevier Ireland Ltd. All rights reserved.

1. Background
The global economic crisis that began in 2008 is likely to
have a lasting negative impact on poverty, nutrition, education and health [1]. Studies of previous economic recessions
have shown that recession affects health primarily through
labour market and healthcare pathways [2], posing poten-

Corresponding author. Tel.: +46 76 101 0711; fax: +46 8 5860 1296.
E-mail address: Jan.Semenza@ecdc.europa.eu (J.C. Semenza).
0168-8510/$ see front matter 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.healthpol.2011.06.013

tial risks and benets. Both fear of job losses and actual
unemployment create short-term risks of poor health from
increased stress, anxiety, and unhealthy coping behaviours
such as hazardous drinking or tobacco use [3,4]. Income
losses may worsen quality of diets but also lead people
to scale back so-called afuent lifestyles, as they spend
less disposable income on tobacco, alcohol, eating outside
the home, and walk instead of drive. Less income effectively increases nancial barriers to accessing health care,
especially in healthcare systems reliant on out-of-pocket
spending. Increasing real prices of medical supplies and

B. Rechel et al. / Health Policy 103 (2011) 168175

services can make health services unavailable or unaffordable [2], exacerbated by potential government budget cuts
of public health services and prevention programmes [5].
The net consequences of these impacts on health can be
difcult to predict [2224].
Although majority of existing studies have focused on
risk factors of chronic noncommunicable disease, concerns have also been expressed that the economic crisis
could have detrimental effects on the spread and control
of communicable diseases [6,7]. A recent systematic literature review on the impact of earlier economic crises
on communicable diseases partially conrms this view
[8], indicating several examples of infectious disease outbreaks from changing human consumption patterns. Two
examples are the spread of West Nile virus in California,
resulting from housing foreclosures and stagnant pools,
creating breeding grounds for mosquitoes [25]; another is
the increase in tick-borne encephalitis in eastern Europe
in regions where people turned to mushroom farming in
an attempt to cope with income losses, increasing their
exposure to ticks [26].
The two main mechanisms identied by which economic crisis could contribute to an increase in communicable disease reects standard Susceptible-Latent-Infected
models of disease spread: (i) by increasing those susceptible in populations, such as an increase in effective contact
rates and exposure to infectious agents and (ii) by constraining the capacity of the health system to respond to
existing and emerging infectious diseases. Thus far, however, evidence on the effects of past crises on infectious
diseases is limited [8]. It is likely that the impact will vary
widely among countries, depending on the epidemiology
and risk factors of particular infectious diseases.
One recent assessment of the potential impact of the
global economic crisis identied implications for tuberculosis and other diseases of poverty arising from changes in
several health systems functions: nancing, prioritization,
government regulation, integration and decentralization
[9]. In this report we draw on that model of key health
system functions, while recognising that control of tuberculosis and other communicable diseases depends as much
on social and economic development as on health systems
responses [10]. The economic and political crisis of the
1990s after the collapse of the Soviet Union was associated
with a rise in incidence of and mortality from tuberculosis in Central and Eastern Europe, and concerns have
been expressed in some countries that the current economic crisis might have similar effects [7]. HIV prevention
and treatment programmes in particular are under threat
with increased risk of HIV transmission and interruptions
or restricted access to antiretroviral treatment [6]. Recent
experience with the H1N1 pandemic shows that infectious disease management can require signicant nancial
resources, despite the relatively small impact of the pandemic [11].
Where quantitative scientic evidence is scarce or
weak, and the epidemiologic situation can change rapidly,
it is relevant to draw on expert opinions about potential
concerns and health effects [12]. In this paper we describe
the ndings of a survey of key informants from across
Europe on the perceived current and potential effects of

169

the recent economic crisis on infectious diseases. In particular, we mapped the key issues of concern to experts
involved in addressing the potential impact of the current
crisis on the spread and control of infectious diseases in
the European Union (EU) and European Free Trade Association (EFTA) countries and identied the types of measures
being undertaken by governments to mitigate any potential adverse effects of the crisis on communicable diseases.
We were especially interested in evidence on the impact
of the crisis on communicable disease control and on those
aspects of health systems most vulnerable to nancial cutbacks, those groups in the population at most risk, and
those communicable diseases most likely to be affected.

2. Methods
Our analysis of expert opinions was a scoping study,
complementing and informing a parallel systematic literature review of the evidence of the impact of previous
economic crises on infectious diseases [8]. A scoping
study differs from a systematic review in that a systematic review might typically focus on a well dened
question where appropriate study designs can be identied in advance whilst a scoping study tends to address
broader topics where many different study designs might
be applicable. Second, the systematic review aims to provide answers to questions from a relatively narrow range
of quality assessed studies, whilst a scoping study is less
likely to seek to address very specic research questions
nor, consequently, to assess the quality of included studies
[13].
The expert survey was undertaken between November 2009 and February 2010. The survey instrument was
piloted between October 2009 and November 2009 with
ve experts in communicable disease control. Surveys were
sent to European Centre for Disease Prevention and Control
(ECDC) Competent Bodies for Scientic Advice. Competent Bodies are institutions or scientic bodies providing
independent scientic and technical advice or capacity for
action in the eld of the prevention and control of infectious diseases; they are ofcial contact points for ECDC,
as designated by Member States governments. The questionnaire was completed by these national representatives
or assigned to other national public health experts with a
leadership position in infectious disease surveillance, and
control in their country. The survey was also disseminated
in the journal Eurosurveillance to capture other infectious
disease experts [3]. Informants completed an on-line questionnaire on the expected impact of the current crisis on the
spread and control of infectious diseases in their country
and corresponding measures being undertaken to mitigate the effects of the crisis [3]. The questionnaire (see
Annex) consisted of 13 questions in the following broad
areas: (a) existing studies, datasets or surveillance by socioeconomic characteristics that would allow monitoring and
assessment of the differential impact of the economic crisis on communicable diseases within the population; (b)
anticipated impact of the economic crisis on communicable disease control; (c) existing policies and programmes to
prevent potential adverse effects, and (d) policies and pro-

170

B. Rechel et al. / Health Policy 103 (2011) 168175

grammes targeting vulnerable or hard-to-reach population


groups.
Simple descriptive statistics have been used for the
quantiable answers. Free-text responses were analysed
to complement the quantitative information.
3. Results
Fifty-four experts from 23 countries, including 19 EU
countries, 3 EFTA countries, and one respondent from
Turkey, answered at least part of the questionnaire. A
list of participating countries and professional positions of
respondents is provided in Table 5. Twenty-seven respondents completed almost all questions of the survey and,
hence, this study draws its results mainly from that subset
of respondents. The remaining 27 respondents restricted
their responses to specic sections based on their area
of expertise. Where appropriate we have included their
responses.
3.1. Monitoring of the impact of the economic crisis on
communicable disease control
The respondents did not identify any research underway or any datasets that would enable monitoring of the
effect of the crisis on the differential incidence of communicable disease in vulnerable groups. There is currently a
limited capacity to monitor the impact of the economic
crisis on communicable disease control. The question of
attribution was highlighted by several respondents: whilst
patterns of communicable disease may be observed, it is
not possible to attribute these changes unambiguously to
the economic crisis as there are many other factors that
may inuence the spread of infections and the response
of health services. For example, one expert mentioned
that in Iceland the incidence of IVDU-related HIV infection has increased signicantly, [but] whether there is
causal relationship with the nancial problems can be
debated. Respondents were not aware of reliable real time
data on the numbers of people within vulnerable groups,
such as homeless people and drug users. However, some
respondents, for example from Norway, noted that as their
country had not been badly affected by the economic crisis,
the anticipated effects on communicable diseases would be
small.
Respondents noted that investigation of the health
effects of the crisis would require linkage of existing
datasets in a manner that is not performed routinely and
cannot be done easily, in particular citing data protection
provisions. As possible data sources they identied hospitalization records, tuberculosis registers, immunization
statistics, insurance data, social benets data, data on needle exchange programmes, and data on drug resistance.
Respondents expressed uncertainty about the dynamics of
vulnerable populations since the beginning of the crisis.
Some respondents expressed concerns that the economic
crisis may lead to increased rates of antibiotic resistant
bacteria and data on prevalence of drug resistant strains,
and specically multi-drug resistant (MDR) tuberculosis,
were considered to be one possible indicator of the effect
of the economic crisis. One respondent drew a compari-

son with what had happened in the economic difculties


accompanying transition in Eastern Europe. More than
half of the respondents (56%) reported that there were
no surveillance programmes in their countries that collect information on any socio-economic characteristics of
those affected (Table 1). Eight respondents reported that
such information is collected in their countries. Examples of
specic surveillance programmes in which socio-economic
data are collected include surveillance of HIV, tuberculosis,
hepatitis C, and sexually transmitted infections (STI). Socioeconomic variables recorded include age, sex, employment,
country of origin, marital status, sexual orientation and
contact history.
Nearly all respondents reported a lack of awareness
of any studies, published or ongoing, that examine the
impact of the current economic downturn on incidence
of infectious diseases. Only one respondent from Portugal
reported an ongoing government programme to monitor
health impacts of the economic crisis. Another respondent
indicated that in countries with small well dened populations, like Iceland, it is relatively easy to gather information
regarding hospitalisations, immunizations, drug use and
infectious disease incidence.
3.2. Anticipated impact of the economic crisis on health
systems, health services, disease surveillance and
communicable disease control programmes
The aspects of communicable disease control considered most likely to be affected by the economic crisis were
nancial and human resources, followed by non-physical
infrastructure and networks such as provision of vaccines
and laboratory networks (Table 2). Several respondents
anticipated that the scope of activities will continue as
before, but implementation of new programmes and initiatives will be prevented or delayed by the crisis. Examples
include new surveillance systems and new immunization
programmes. The nancial constraints were also seen as
impacting on the spread of communicable diseases globally
as a result of decreasing funding for developing countries,
with consequences for tuberculosis, HIV and malaria control programmes.
Lack of human resources, understafng, recruitment
freezes, reductions in the workforce and staff turnover
were reported as demonstrable consequences of the economic crisis (Table 3). About 72% of the respondents
anticipated that understafng would impact on control of
communicable diseases due to limited capacity to confront
emerging clinical, prevention or surveillance challenges:
respondents from the UK, for example, expressed concerns
that they would not be allowed to recruit staff to perform the roles of the surveillance programmes (the survey
was conducted before the governments announcement in
July 2010 that it will re-organize the Health Protection
Agency) [14]. One respondent from the UK warned of a
deterioration in morale because of anxiety about reform
of the health service. In Iceland, increasing turnover of
staff in primary health care led to concern about the quality of surveillance data. Some countries have already been
experiencing physician brain drain with loss of junior
specialists from the health sector. In Portugal, the current

B. Rechel et al. / Health Policy 103 (2011) 168175

171

Table 1
Policies and programmes of communicable disease control likely to be affected by the current economic crisis.
Question

Number of
respondents

Yes (%)

No (%)

Dont know (%)

Examples of policies and programmes


provided by the survey respondents

Are there any NATION-WIDE


communicable disease surveillance
programmes that are particularly likely
to be affected by the current economic
crisis?

27

33.3

48.1

18.5

Are there any SUB-NATIONAL or


REGIONAL communicable disease
surveillance programmes that are
particularly likely to be affected by the
current economic crisis?
Have there been specic policies or
programmes in your country to
prevent or reduce any potential
negative effects of the economic crisis
on communicable diseases?
Are there particular policies or
programmes for communicable
disease control targeting vulnerable or
hard-to-reach population groups in
your country in times of economic
crisis or in general?

27

14.8

59.3

25.9

Tuberculosis
Antimicrobial resistance
National immunization programmes
Surveillance of STI
Programmes in developing countries
(tuberculosis, malaria, HIV, inuenza
A)
Reduction in the workforce and
recruitment freeze
Antimicrobial resistance

27

3.7

85.2

11.1

Strengthening of health
infrastructure
Global vaccination programme
Quality improvement

27

40.7

44.4

14.8

Are there any examples of


communicable disease surveillance
that collect information on the social
or economic characteristics of those
affected in your country?

27

29.6

55.5

14.8

Hepatitis B vaccination of homeless


and drug users
Community health mediators to
facilitate access to primary health care
Needle exchange programmes
Collaborative programmes for people
with co-existing mental health
problems, drug use, language barriers
Special programmes for (illegal)
immigrants, sex-workers, homeless,
HIV positive
HIV surveillance
Tuberculosis
STI
Hepatitis C

crisis coincided with ongoing health sector reforms viewed


as having neglected public health services and the public health workforce in primary care and local authorities
(public health physicians, public health nurses, environmental technicians).
Preventive services, in-patient care and surveillance
were considered to be most at risk (Table 2). Surveillance
programmes depend on stability of nancial resources,
infrastructure and human resources. 32% of the respondents expressed concern that nationwide surveillance

programmes were likely to be affected, particularly those


that have recently started, such as those for Campylobacter in Austria and STI surveillance in Malta. A reduction in
the workforce is perceived as an obstacle to surveillance
programmes and to the quality of the data collected.
Immunization programmes were the most frequently
mentioned preventive programmes that might be affected,
in addition to awareness campaigns targeting vulnerable groups, and antibiotics management to prevent the
emergence and spread of resistant bacteria. Two respon-

Table 2
Likely impact of the economic crisis on aspects of communicable disease control systems and health services.
Number of respondents
Aspects of the health system for the control of communicable diseases
27
Financial resources
25
Human resources
28
Non-physical
infrastructure/networks (e.g.
provision of vaccines,
laboratory network, etc.)
26
Physical infrastructure (e.g.
buildings, equipment, etc.)
Aspects of the health service for the control of communicable diseases
25
Prevention of disease
24
In-patient care
25
Surveillance
25
Out-patient care/follow-up
care
Primary care
25

Will deteriorate (%)

Will improve (%)

Dont know (%)

85.2
72.0
57.1

3.7
4.0
17.9

11.1
24.0
25.0

42.3

15.4

42.3

68.0
50.0
44.0
44.0

20.0
16.7
24.0
16.0

12.0
33.3
32.0
40.0

28.0

32.0

40.0

172

B. Rechel et al. / Health Policy 103 (2011) 168175

Table 3
Analysis of free-text responsesmost frequently identied aspects of communicable disease control.
Disease/risk group/aspect mentioned by respondents

Times mentioned in free-text


responses

Diseases
Tuberculosis/TB
HIV/AIDS
STI/syphilis/LGV/STD
Hepatitis B/hepatitis C/hepatitis
Inuenza A/u/pandemic

14
9
9
5
5

Risk groups
Migrants/in Europe/persons from third world countries seeking work here/sub-Saharan
Africans/language barriers
Drug users/drug abusers/drug addicts/IVDU/needle exchange
Homeless
Gay men/MSM
Aspects of communicable disease control
Vaccination/immunization/vaccine/HPV/VZV
Human resources/understafng/brain drain/turnover of staff/reduction in the workforce/lack of
human infrastructure
Drug resistance/resistant bacteria/MDR TB/AMR/resistant cases/resistance management
Quality of data/quality control of microbiological diagnosis/quality improvement/poor quality
Screening
Inner cities/major cities

dents suggested that the nancial constraints facing health


services mean that introduction of many effective new vaccines will be delayed, such as the pneumococcal, human
papillomavirus, varicella-zoster virus and new combined
vaccines.
Programmes considered at particular risk of disinvestment include infectious disease research programmes
(56% of respondents) and hospital infection control activities (54% of respondents). Nearly half of the respondents
(46%) considered that capacity in the health service to
respond to outbreaks would be weakened. Although outbreak response capacity has been tested with pandemic u,
the experience was not considered necessarily replicable
for other diseases.
Respondents in some European countries described
how certain aspects of communicable disease control had
been sub-optimal even before the economic crisis. For
example, respondents from Portugal and Malta reported
that occupational health programmes either do not exist
or have been of poor quality. Others mentioned that prevention and management of antimicrobial drug resistance
was problematic. They expressed concern about the consequences of any further deterioration, describing the
implications as potentially dangerous.
In some countries, the economic crisis coincides with
ongoing reforms of primary care and hospital care. There
have been concerns that the reforms will put additional
pressure on health budgets both from government and private sources, which may result in poorer outcomes in the
health sector, including communicable disease control.
3.3. Strategies to mitigate the effects of the economic
crisis on communicable disease control
85% of respondents reported that there were no specic policies or programmes in their countries to prevent
or reduce any potential negative effects of the economic
crisis on communicable diseases (Table 1). A further 11%

14
9
8
4
19
9
7
4
3
2

did not know about such policies or programmes. Only


one respondent, from Turkey, identied strategies to mitigate the effect of economic crisis including strengthening
of health infrastructure and vaccination programmes and
quality improvement.
3.4. Communicable disease control programmes
targeting vulnerable and hard-to-reach groups
As it is already widely expected that the groups most
likely to be affected will be among vulnerable and hard
to reach populations, we sought to determine whether
there are specic programmes for them. The most commonly mentioned vulnerable groups at particular risk of
communicable diseases included migrants, illegal immigrants, drug users and homeless people (Table 3). One
respondent from Romania noted that the development
of successful programmes for vulnerable groups requires
nancial sustainability, and therefore the economic crisis
is a potential threat to such programmes. 41% of the respondents identied examples of programmes in their countries
that target vulnerable groups. These included programmes
for improving access to primary health care (community health mediators) and interagency programmes to
reach people with co-existing social and health problems such as mental health and drug-related problems,
language barriers or other socio-demographic characteristics. Hepatitis B vaccination for homeless and drug
users, needle exchange programmes and screening of illegal immigrants for communicable diseases were other
examples of targeted interventions. 67% of participants
expected that services aimed at particularly vulnerable
groups would deteriorate as a result of the economic crisis
(Table 4).
Thirteen respondents identied programmes targeting
vulnerable groups that they considered especially successful. Examples from the UK include tuberculosis tracing
and treatment in inner city areas and among the migrant

B. Rechel et al. / Health Policy 103 (2011) 168175

173

Table 4
Aspects of communicable disease control programmes that may be affected by the current economic crisis.
Aspect

Number of respondents

Will deteriorate (%)

No effect (%)

Services aimed at
particularly vulnerable
groups
Infectious disease research
programmes
Hospital infection control
activities
Health service capacity to
respond to outbreaks
Diagnostic microbiology
provision services
Community infection
control activities including
contact tracing
Service provision for
patients with infectious
diseases
Occupational health
services
Immunization programmes
Genito-urinary medicine
provision
Food safety inspection
Travel medicine

27

66.7

18.5

Will improve (%)


7.4

Dont know (%)


7.4

27

55.6

25.9

11.1

7.4

26

53.8

26.9

11.5

7.7

26

46.2

38.5

7.7

7.7

26

42.3

34.6

15.4

7.7

27

37.0

51.9

7.4

3.7

27

37.0

48.1

11.1

3.7

26

30.8

46.2

3.8

19.2

27
27

29.6
18.5

55.6
48.1

7.4
0

7.4
33.3

27
27

14.8
11.1

55.6
59.3

11.1
7.4

18.5
22.2

Table 5
List of participating countries and positions of respondents.
Country (alphabetically)

Number of participants

Professional positions held (alphabetically)

Austria
Belgium
Bulgaria
Denmark
Estonia
France
Hungary
Iceland
Ireland
Italy
Latvia
Luxembourg
Malta
Netherlands
Norway
Poland
Portugal
Romania
Spain
Sweden
Switzerland
Turkey
UK

2
3
1
1
2
4
3
1
2
4
2
1
4
1
1
3
1
2
3
3
1
1
8

Consultant in infection prevention


Consultant in infectious diseases and microbiology
Consultant microbiologist
Coordinator of early detection of community epidemics
Deputy director of national centre for infectious diseases
Director, department of epidemiology
Epidemiologist; Hospital epidemiologist; Head of Epidemiology unit
Family doctor
Head of department at national centre for epidemiology
Head of department of epidemiology and clinical microbiology at national institute
Head of division human medicine at national agency for health and food safety
Head of infectious disease prevention and control unit
Head of infectious diseases department
Head of research department, national centre for infections
Head of surveillance unit, national health laboratory
Head of WHO collaborating centre on infectious diseases
Health inspector
Medical director, national lung and TB association
Microbiologist
Microbiology director
Responsible for TB control at health department
Specialist registrar in public health
University lecturer, department of microbiology
University professor

community; u vaccination of the elderly population;


hepatitis vaccination programmes; and immunization of
pre-school children. In France, vulnerable people are
encouraged to attend vaccination centres, where nancial
and material assistance is provided by the government.
Respondents from Malta cited screening of immigrants for
tuberculosis. In Belgium a project for HIV and STI testing on location in saunas and bars reportedly showed
good results. Centres for free and anonymous testing had
recently opened in Antwerp and Brussels and were successful in reaching different target groups, especially gay men.

4. Discussion
To the best of our knowledge this is the rst attempt
to elicit and synthesise expert opinions on the impact of
the current economic crisis on communicable disease epidemiology and policy in Europe. In the light of limited
evidence from previous economic crises, and in the absence
of quantitative evidence on the current crisis, undertaking
a qualitative exercise offers a means of at least partially
lling this important gap and may help inform policy and
research responses.

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B. Rechel et al. / Health Policy 103 (2011) 168175

Our ndings suggest that currently there is limited


capacity in EU countries to monitor the impact of the economic crisis on communicable disease control. It appears
that there are no specic policies or programmes to
prevent any potential negative effects of the crisis on
communicable diseases. The aspects most likely to be
affected are nancial and human resources and nonphysical infrastructures, such as provision of vaccines
and laboratory networks. Preventive services (immunization programmes, awareness campaigns among vulnerable
groups) and surveillance programmes were considered to
be most at risk of disinvestment, as well as infectious
diseases research, hospital infection control activities and
capacity of health systems to respond to outbreaks.
Any impact of the crisis on communicable disease control is likely to involve a variety of interlinked pathways
including: increased prevalence of risk factors for spread
of infection and development of disease in infected individuals; increased pool of susceptible populations and of
particularly vulnerable groups; restricted access to care;
and health services restructuring and funding cuts which
may impact on their capacity to respond to communicable
diseases.

4.1. Increased prevalence of risk factors and increased


pool of susceptible and particularly vulnerable population
groups
Economic hardship is associated with higher risk of
infectious diseases. Poverty, unemployment, malnutrition,
lower educational attainment, overcrowded living conditions, recent migration status, and homelessness are
among the recognised risk factors for infectious diseases
[11,15,16,27]. The participants in this study identied
homeless people, migrants and drug users as groups at
higher risk (Table 3), but expressed uncertainty about
the dynamics of vulnerable populations. Although reliable
data are lacking, it is very likely that the economic crisis will have increased the pool of vulnerable population
groups.
More than 5 million people became unemployed in the
EU compared with the pre-crisis period [17], with unemployment rising from 8.7% in April 2009 to 9.7% in April
2010 and 2.4 million people losing their jobs in this period.
Unemployment rates vary greatly across countries, with
the lowest ofcial rate in the Netherlands (4.1%) and the
highest in Latvia (22.5%) [18]. The implications include
loss of income, increasing rates of poverty and indebtedness and rising homelessness. Recent national data on
the number of homeless people show that the situation
has worsened in a number of EU countries. Over 15%
of people in the EU live in overcrowded accommodation
[17].
The economic crisis is likely to have an impact on
migration as people move across borders in search of
employment. Migrant workers may be particularly vulnerable to the economic downturn, since they often do not
have the same rights as citizens of destination countries
[19]. The rate of unemployment among migrants (19.1%) is
double the overall unemployment rate in the EU [17].

4.2. Restricted access to health care


The majority of participants in our survey anticipated
that services aimed at vulnerable people will deteriorate
as a result of the economic crisis. There is already evidence
that the current economic crisis has impacted on health
care seeking behaviour particularly of vulnerable groups
and has led to decrease in the utilization of health care
services [20]. This effect was more pronounced in countries with higher private expenditure on health care. When
symptomatic patients fail to seek medical care this may
result in delays in diagnosis and initiation of treatment and
increased risk of spread of infection in the community [28].
4.3. Health services restructuring and capacity to
respond to communicable diseases
Nearly 86% of the respondents in this study believe that
nancial resources for communicable disease control will
deteriorate as a result of the recession. The NHS in England
for example is facing cuts of up to 20bn (D 24.3bn) by
2014 [21]. NHS organizations are required to make savings
through management costs cuts and a recruitment freeze.
The Royal College of Nursing estimates that more than
5000 nurse posts will be lost in England [21]. Respondents
in our survey expressed concerns that funding cuts and
reductions in the public health workforce would impact
on surveillance programmes, preventive services and
research. Cuts on such scales will almost certainly be
impossible without reducing quality of care and reducing
access to services.
In interpreting the above ndings it is essential to be
aware of the limitations of this small qualitative review.
About half of the respondents did not ll in most of
the questions. This may reect considerable uncertainty
among participants about the likely impact of the current
economic crisis. Thus, the results should be interpreted
with caution, as they draw on the opinions of only a small
sample of experts who may not be representative of the
communicable disease control workforce in Europe. Nevertheless, the range of responses from a variety of countries
provides some insight into likely changes.
5. Conclusions
Our respondents were unable to identify studies,
databases or routinely collected socio-economic indicators
that would enable monitoring the effects of the economic downturn on communicable diseases incidence and
outcomes. There are few specic national policies and programmes seeking to reduce the impact of the economic
crisis on systems of communicable disease control. Services
aimed at vulnerable and hard-to-reach population groups
are perceived to be particularly at risk in the current nancial climate. Potential disinvestment in health services, as
governments seek to reduce public spending, may pose a
risk to communicable disease control. Yet, as history, from
the plague of Athens to the emergence of BSE have shown,
the cost of failure to invest could be much greater in the
long run.

B. Rechel et al. / Health Policy 103 (2011) 168175

Acknowledgements
We would like to thank all participants in the survey
who contributed their time to this study. The study was
funded by the European Centre for Disease Control and Prevention. We thank in particular Sandra Alves from ECDC for
your valuable help in disseminating the questionnaire.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the online version, at
doi:10.1016/j.healthpol.2011.06.013.
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