Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990–2010

a longitudinal analysis

Mahiben Maruthappu, Johnathan Watkins, Aisyah Mohd Noor, Callum Williams, Raghib Ali, Richard Sullivan, Thomas Zeltner, Rifat Atun

    Research output: Contribution to journalArticle

    Abstract

    Background The global economic crisis has been associated with increased unemployment and reduced public-sector expenditure on health care (PEH). We estimated the effects of changes in unemployment and PEH on cancer mortality, and identified how universal health coverage (UHC) affected these relationships. Methods For this longitudinal analysis, we obtained data from the World Bank and WHO (1990–2010). We aggregated mortality data for breast cancer in women, prostate cancer in men, and colorectal cancers in men and women, which are associated with survival rates that exceed 50%, into a treatable cancer class. We likewise aggregated data for lung and pancreatic cancers, which have 5 year survival rates of less than 10%, into an untreatable cancer class. We used multivariable regression analysis, controlling for country-specific demographics and infrastructure, with time-lag analyses and robustness checks to investigate the relationship between unemployment, PEH, and cancer mortality, with and without UHC. We used trend analysis to project mortality rates, on the basis of trends before the sharp unemployment rise that occurred in many countries from 2008 to 2010, and compared them with observed rates. Results Data were available for 75 countries, representing 2·106 billion people, for the unemployment analysis and for 79 countries, representing 2·156 billion people, for the PEH analysis. Unemployment rises were significantly associated with an increase in all-cancer mortality and all specific cancers except lung cancer in women. By contrast, untreatable cancer mortality was not significantly linked with changes in unemployment. Lag analyses showed significant associations remained 5 years after unemployment increases for the treatable cancer class. Rerunning analyses, while accounting for UHC status, removed the significant associations. All-cancer, treatable cancer, and specific cancer mortalities significantly decreased as PEH increased. Time-series analysis provided an estimate of more than 40 000 excess deaths due to a subset of treatable cancers from 2008 to 2010, on the basis of 2000–07 trends. Most of these deaths were in non-UHC countries. Interpretation Unemployment increases are associated with rises in cancer mortality; UHC seems to protect against this effect. PEH increases are associated with reduced cancer mortality. Access to health care could underlie these associations. We estimate that the 2008–10 economic crisis was associated with about 260 000 excess cancer-related deaths in the Organisation for Economic Co-operation and Development alone. Funding None.

    Original languageEnglish (US)
    Pages (from-to)684-695
    Number of pages12
    JournalThe Lancet
    Volume388
    Issue number10045
    DOIs
    StatePublished - Aug 13 2016

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    Universal Coverage
    Unemployment
    Economics
    Mortality
    Health
    Neoplasms
    Lung Neoplasms
    Survival Rate
    Health Services Accessibility
    United Nations
    Public Sector
    Health Expenditures

    ASJC Scopus subject areas

    • Medicine(all)

    Cite this

    Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990–2010 : a longitudinal analysis. / Maruthappu, Mahiben; Watkins, Johnathan; Noor, Aisyah Mohd; Williams, Callum; Ali, Raghib; Sullivan, Richard; Zeltner, Thomas; Atun, Rifat.

    In: The Lancet, Vol. 388, No. 10045, 13.08.2016, p. 684-695.

    Research output: Contribution to journalArticle

    Maruthappu, M, Watkins, J, Noor, AM, Williams, C, Ali, R, Sullivan, R, Zeltner, T & Atun, R 2016, 'Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990–2010: a longitudinal analysis', The Lancet, vol. 388, no. 10045, pp. 684-695. https://doi.org/10.1016/S0140-6736(16)00577-8
    Maruthappu, Mahiben ; Watkins, Johnathan ; Noor, Aisyah Mohd ; Williams, Callum ; Ali, Raghib ; Sullivan, Richard ; Zeltner, Thomas ; Atun, Rifat. / Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990–2010 : a longitudinal analysis. In: The Lancet. 2016 ; Vol. 388, No. 10045. pp. 684-695.
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    title = "Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990–2010: a longitudinal analysis",
    abstract = "Background The global economic crisis has been associated with increased unemployment and reduced public-sector expenditure on health care (PEH). We estimated the effects of changes in unemployment and PEH on cancer mortality, and identified how universal health coverage (UHC) affected these relationships. Methods For this longitudinal analysis, we obtained data from the World Bank and WHO (1990–2010). We aggregated mortality data for breast cancer in women, prostate cancer in men, and colorectal cancers in men and women, which are associated with survival rates that exceed 50{\%}, into a treatable cancer class. We likewise aggregated data for lung and pancreatic cancers, which have 5 year survival rates of less than 10{\%}, into an untreatable cancer class. We used multivariable regression analysis, controlling for country-specific demographics and infrastructure, with time-lag analyses and robustness checks to investigate the relationship between unemployment, PEH, and cancer mortality, with and without UHC. We used trend analysis to project mortality rates, on the basis of trends before the sharp unemployment rise that occurred in many countries from 2008 to 2010, and compared them with observed rates. Results Data were available for 75 countries, representing 2·106 billion people, for the unemployment analysis and for 79 countries, representing 2·156 billion people, for the PEH analysis. Unemployment rises were significantly associated with an increase in all-cancer mortality and all specific cancers except lung cancer in women. By contrast, untreatable cancer mortality was not significantly linked with changes in unemployment. Lag analyses showed significant associations remained 5 years after unemployment increases for the treatable cancer class. Rerunning analyses, while accounting for UHC status, removed the significant associations. All-cancer, treatable cancer, and specific cancer mortalities significantly decreased as PEH increased. Time-series analysis provided an estimate of more than 40 000 excess deaths due to a subset of treatable cancers from 2008 to 2010, on the basis of 2000–07 trends. Most of these deaths were in non-UHC countries. Interpretation Unemployment increases are associated with rises in cancer mortality; UHC seems to protect against this effect. PEH increases are associated with reduced cancer mortality. Access to health care could underlie these associations. We estimate that the 2008–10 economic crisis was associated with about 260 000 excess cancer-related deaths in the Organisation for Economic Co-operation and Development alone. Funding None.",
    author = "Mahiben Maruthappu and Johnathan Watkins and Noor, {Aisyah Mohd} and Callum Williams and Raghib Ali and Richard Sullivan and Thomas Zeltner and Rifat Atun",
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    T1 - Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990–2010

    T2 - a longitudinal analysis

    AU - Maruthappu, Mahiben

    AU - Watkins, Johnathan

    AU - Noor, Aisyah Mohd

    AU - Williams, Callum

    AU - Ali, Raghib

    AU - Sullivan, Richard

    AU - Zeltner, Thomas

    AU - Atun, Rifat

    PY - 2016/8/13

    Y1 - 2016/8/13

    N2 - Background The global economic crisis has been associated with increased unemployment and reduced public-sector expenditure on health care (PEH). We estimated the effects of changes in unemployment and PEH on cancer mortality, and identified how universal health coverage (UHC) affected these relationships. Methods For this longitudinal analysis, we obtained data from the World Bank and WHO (1990–2010). We aggregated mortality data for breast cancer in women, prostate cancer in men, and colorectal cancers in men and women, which are associated with survival rates that exceed 50%, into a treatable cancer class. We likewise aggregated data for lung and pancreatic cancers, which have 5 year survival rates of less than 10%, into an untreatable cancer class. We used multivariable regression analysis, controlling for country-specific demographics and infrastructure, with time-lag analyses and robustness checks to investigate the relationship between unemployment, PEH, and cancer mortality, with and without UHC. We used trend analysis to project mortality rates, on the basis of trends before the sharp unemployment rise that occurred in many countries from 2008 to 2010, and compared them with observed rates. Results Data were available for 75 countries, representing 2·106 billion people, for the unemployment analysis and for 79 countries, representing 2·156 billion people, for the PEH analysis. Unemployment rises were significantly associated with an increase in all-cancer mortality and all specific cancers except lung cancer in women. By contrast, untreatable cancer mortality was not significantly linked with changes in unemployment. Lag analyses showed significant associations remained 5 years after unemployment increases for the treatable cancer class. Rerunning analyses, while accounting for UHC status, removed the significant associations. All-cancer, treatable cancer, and specific cancer mortalities significantly decreased as PEH increased. Time-series analysis provided an estimate of more than 40 000 excess deaths due to a subset of treatable cancers from 2008 to 2010, on the basis of 2000–07 trends. Most of these deaths were in non-UHC countries. Interpretation Unemployment increases are associated with rises in cancer mortality; UHC seems to protect against this effect. PEH increases are associated with reduced cancer mortality. Access to health care could underlie these associations. We estimate that the 2008–10 economic crisis was associated with about 260 000 excess cancer-related deaths in the Organisation for Economic Co-operation and Development alone. Funding None.

    AB - Background The global economic crisis has been associated with increased unemployment and reduced public-sector expenditure on health care (PEH). We estimated the effects of changes in unemployment and PEH on cancer mortality, and identified how universal health coverage (UHC) affected these relationships. Methods For this longitudinal analysis, we obtained data from the World Bank and WHO (1990–2010). We aggregated mortality data for breast cancer in women, prostate cancer in men, and colorectal cancers in men and women, which are associated with survival rates that exceed 50%, into a treatable cancer class. We likewise aggregated data for lung and pancreatic cancers, which have 5 year survival rates of less than 10%, into an untreatable cancer class. We used multivariable regression analysis, controlling for country-specific demographics and infrastructure, with time-lag analyses and robustness checks to investigate the relationship between unemployment, PEH, and cancer mortality, with and without UHC. We used trend analysis to project mortality rates, on the basis of trends before the sharp unemployment rise that occurred in many countries from 2008 to 2010, and compared them with observed rates. Results Data were available for 75 countries, representing 2·106 billion people, for the unemployment analysis and for 79 countries, representing 2·156 billion people, for the PEH analysis. Unemployment rises were significantly associated with an increase in all-cancer mortality and all specific cancers except lung cancer in women. By contrast, untreatable cancer mortality was not significantly linked with changes in unemployment. Lag analyses showed significant associations remained 5 years after unemployment increases for the treatable cancer class. Rerunning analyses, while accounting for UHC status, removed the significant associations. All-cancer, treatable cancer, and specific cancer mortalities significantly decreased as PEH increased. Time-series analysis provided an estimate of more than 40 000 excess deaths due to a subset of treatable cancers from 2008 to 2010, on the basis of 2000–07 trends. Most of these deaths were in non-UHC countries. Interpretation Unemployment increases are associated with rises in cancer mortality; UHC seems to protect against this effect. PEH increases are associated with reduced cancer mortality. Access to health care could underlie these associations. We estimate that the 2008–10 economic crisis was associated with about 260 000 excess cancer-related deaths in the Organisation for Economic Co-operation and Development alone. Funding None.

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