The results support the hypothesis that those countries that have applied and maintained high levels of austerity have experienced adverse consequences for children with worsening SDCH, CHO and reduced access to, and quality of, preventive and curative healthcare services. These negative impacts on child health and development may have implications for the future adult health of a generation.
The results of the present study corroborate other studies at the European general population level.1, 6 Although there are many differences between countries, according to these studies, results suggest that the interaction of fiscal austerity with economic shocks and weak social protection ultimately may produce greater social crisis with a negative impact on health. Moreover, in countries that applied high levels of austerity, another review at the European general population level showed an increase in homelessness, and food insecurity, and worsening mental health and increase of suicide rates, as well as difficulties with access to care.2 The latter study also shows that in Greece, Spain, UK, and France charities also reported marked rises in people seeking emergency food support coinciding with the introduction of austerity measures.
The present review shows significant variability in the situation of European countries before and during the crisis. Classification of countries according to the level of austerity also shows an important variability. However, the results are consistent with respect to the impact of austerity measures on SDCH and CHO.
Poverty reduction strategies, either in-kind or cash benefits, were suggested to be less effective as a result of austerity measures employed by governments. 18, 19 Investment in family and child policies declined during the study period even in countries that traditionally invested more, and was clearly insufficient in countries such as Spain and Portugal.20, 23 And these changes coincide again, with the period of greatest adjustment for austerity.
The impact on children’s health has been detected especially in perinatal indicators and in countries that have significantly reduced the healthcare budget, such as Greece.17 The impact has been greater in families with vulnerable children and a very important change has been detected in the access to, and provision of, services for children with disabilities and in child mental health services. Simultaneously, the global migrant and refugee crisis has reached historically high rates, and the interactive effects of these two factors in Greece were associated with a deterioration in child mental health.30
Austerity measures have been described to impact deprived groups the most.2 In this sense, children represent a particularly vulnerable population group. Inequalities in early child development have been identified as a major contributing factor to inequalities in adult health.31 Besides the studies included in the present review, the recent increase in infant mortality in the poorest areas of England associated with rising child poverty would also be associated to the impact of austerity policies,32 and the need to urgently address these policies for the real protection of families and children.
Despite almost all of the included studies showed low risk of bias there are some limitations. First, the analysis of ecological data prevents the establishment of causal associations. Moreover, some studies comparing SDCH included ecologic exposure or outcome measures which prevents application of some items in STROBE. Nevertheless, almost all included studies show that a high level of austerity is associated with worse outcomes in SDCH. Secondly, differences in classifications used to assess the level of austerity make it difficult to establish comparisons and summary measures. Moreover, these classifications do not discriminate well between specific aspects of budget reduction, such as family benefits, early child investment, prenatal care, etc. It may not adequately reflect specific national policies that establish general economic rigor while trying to protect the most vulnerable groups, such as children. This could partly explain why Iceland,26 despite having a high level of austerity at the beginning of the economic crisis and in response to the crisis, showed trends more consistent with countries with low levels of austerity and protecting social benefits for children. On the other hand, almost all included studies agree that countries such a Greece, Spain, Portugal or the UK applied higher levels of austerity than the rest. Thirdly, the difficulties establishing causal associations between exposure and outcomes is well known especially in the case of comparisons such as those carried out in the present study. Finally, there is a lack of studies of trends in gradients in social inequalities in child health, while studies at the general population level showed an increase in inequalities during the recession and austerity periods.33 A study that analysed the investment per child in England according to the area of residence found a greater reduction in areas with greater deprivation, a fact that the authors called the inverse intervention law.34 In summary, this review highlights the need for more robust studies of the impact of austerity on child health in individual countries.