Many political economists see effective states as those stemming from ‘top-down’ directives by governments. Investments into state capacity by incumbents, such as establishing an effective bureaucracy, increase the range of policies a government can implement successfully. Citizen compliance with policies is either assumed or, alternatively, achieved via coercion by law enforcement.

A second approach to state building stresses the role of individuals. Here, citizens and the government work in a mutually reinforcing, reciprocal relationship (Besley, 2021). ‘Bottom-up’ private action can similarly enhance state effectiveness.

If government is perceived to be trustworthy, people will be more likely to comply with public policies via consent. Public trust in government and the state is therefore crucial for increasing voluntary compliance.

Governments can achieve more if they know that citizens trust that policy-makers have their best interests at heart. And while it is easy to see how public trust can be eroded, (re)building trust is pivotal and can be challenging.

The importance of public trust

Trust in government and the state matters for a variety of reasons. Primarily, it increases voluntary compliance towards public policies. If we think of state capacity broadly as ’the government’s ability to accomplish its intended policy goals’, it stands to reason that compliance serves an essential purpose (Dincecco, 2017).

The archetypal example of state capacity is fiscal capacity – referring to the state’s ability to increase tax revenues to fund public goods and services for society (Besley and Persson, 2011). Investments into fiscal capacity typically involve strengthening bureaucracies and establishing fair and transparent tax systems, part of which involves improved monitoring. Citizen compliance with paying one’s taxes is therefore a direct function of the state’s oversight and reach to enforce tax policy (Allingham and Sandmo, 1972).

At the same time, if people think that tax revenues are well spent on public goods and services – with government proving its trustworthiness against profligacy as a result – this should increase society’s intrinsic willingness to pay taxes (Levi, 1988). In economics, this is sometimes known as ‘tax morale’ (Luttmer and Singhal, 2014).

Trust in government is crucial to establishing norms of compliance towards taxes (OECD, 2019). And compliance via consent, as opposed to compulsion, is a substantially cheaper method to implement effective policies (Tyler, 2006).

Supporting fiscal capacity via tax morale is one example of how voluntary compliance enhances state capacity via trust in government. But there are a range of other policies that require high levels of compliance to be successful, beyond just taxes. And there are also a host of activities by which citizens interact with the state on key issues which require public trust.

The Covid-19 pandemic is a useful setting to explore this idea further. Across countries, vaccine rollouts have almost exclusively been administered by the state (as opposed to private companies). Trust in government has therefore been necessary to incentivise people to get vaccinated (and to thwart conspiracy theories that go against government-backed scientific advice).

Even before the pandemic, there was evidence of a strong association between public trust and inoculation willingness (Blair et al, 2017). Political trust during Covid-19 has also been associated with greater compliance with lockdown policies (Bargain and Aminjonov, 2020). Clearly, with a public health emergency like Covid-19, trust in government has been a vital asset for delivering effective interventions such as the vaccine rollout.  

Direct measures of compliance are possible on a policy-by-policy basis. But micro-data can provide some insights into cross-national trends. An index of voluntary compliance can be constructed by looking at respondents’ willingness to fight for their country, pay taxes and accept higher taxes to prevent environmental pollution (Besley, 2022). Conscription and taxes are two well-studied areas of compliance-based interactions with the state (Levi, 1997).

This work shows a strong positive correlation between the proportion of respondents who report high confidence in government and the voluntary compliance index (see Figure 1). Although not causal evidence, it highlights that trust and compliance are closely related.

Figure 1: Trust and compliance, by country

Source: Integrated Values Survey

Levels of political trust across the UK

Trust in government is relevant to every country’s political life. Recent political events have focused significant attention on this to the UK. In the first Conservative Party leadership debate to replace Boris Johnson, trust was the first issue highlighted, and was subsequently discussed at length.

Indeed, only 35% of the UK population trust the government, according to new data from the Office for National Statistics (ONS). This is below the OECD average of 41%.

While trust in government is crucial, there are several other branches of the state that citizens can have faith in. Local government is typically deemed more trustworthy than national government. This is partly because people have more interaction with local public services and have greater access to, say, local councillors compared with MPs in Westminster (Jennings, 1998).

The ONS findings show that 42% of people in the UK trust local government – a notably higher share than for national government. The data also indicate that trust is higher in the civil service, at 55%. Given civil servants are impartial bureaucrats, this should overcome public trust as being driven purely by partisan ties (for example, Conservative voters will be more likely to trust a Conservative government versus a Labour one). Political parties are actually the state institution with the lowest level of trust among the public, at 20%.

Figure 2: Trust in political institutions

Source: ONS

The ONS findings are a static snapshot of the distribution of public trust in 2022. Ideally, we also want to understand how trust has evolved over time. The available data from the OECD going back to 2010 show that trust in government dropped to around 35% in 2019, where it has remained since.

This stands below the 2010-2020 average of 42% (the pale blue line in Figure 3). Although speculative, it seems that Brexit, Boris Johnson’s premiership and Covid-19 are plausible drivers of this trend.

Figure 3: Trust in UK government (2010-2020)

Source: OECD

Why should governments build trust?

Declining public trust in government is worrying. The Covid-19 pandemic has tested public trust around the world. As the worst of the crisis subsides, (re)building trust will be pivotal not only to expand state capacity as a long-term project, but to also tackle future crises.

There are a range of issues which require government and their citizens to work together. The threat of climate change is a clear example. Governments must implement the right environmental policies to encourage a green transition.

Evidence suggests that such policies can help shift households’ habits towards greener patterns of consumption – although this logic is yet to be extended to firms and production tendencies (Nyborg et al, 2016; Mattauch et al, 2022). But for these theoretical ideas to work in practice, compliance will be necessary and cannot be taken for granted.

The OECD’s trust survey report shows that across OECD countries, half of individuals think that climate change should be prioritised by government, but only one-third are confident in policy success on this issue.

Across UK regions and the devolved nations there is also a positive correlation between confidence in government and citizens’ willingness to sacrifice income for the environment (see Figure 4). This relates to growing evidence on linking trust to climate policy preferences (Klenert et al, 2018; Dechezleprêtre et al, 2022). This also indicates that political trust matters for enhancing voluntary compliance to solve crises such as climate change, by increasing the range of policies available to policy-makers.

Figure 4: Political trust and environmental preferences, by UK nation/region

Source: Integrated Values Survey

How to build trust in government?

The drivers of mistrust in government are to some extent fairly obvious. Corruption is a case in point. If people see politicians using public office for private gain, they will be less likely to believe that government has their best interests at heart. Why would any household or firm pay taxes if they knew the money was being used to line politicians’ pockets?

Evidence that policy-makers are not following the rules, regulations or laws that they set also decreases public trust. ‘Partygate’ and the Dominic Cummings affair in the UK are evidence of this. Respect for the rule of law by those working in government is paramount for maintaining trust, ensuring there is sufficient compliance for delivering effective policy.

In terms of building trust in the state, proving policy competence is one method. Successful delivery of public goods and services, to increase the welfare of citizens, can be highly effective. The United States in the 1930s is a clear historical example. Recent evidence suggests that Americans who benefited from President Franklin  D. Roosevelt’s ‘New Deal’ – at the time, an unprecedented expansion of the state – were far more willing to voluntarily contribute to the war effort during the Second World War (Caprettini and Voth, 2022).

As with the case for tax morale, people are more likely to trust government, and voluntarily comply with policies, if government is perceived to work in citizens’ best interests.

Increasing the scope of public engagement with politics is also an important driver of public trust (Kumagai and Iorio, 2020). Legal scholars have emphasised the importance of ‘legitimacy’ – individuals tend to obey the law not from fear of sanctions, but because they see the law as a legitimate moderator of human behaviour (Levi et al, 2012).

A greater commitment to procedural fairness and amplifying people’s voices in the political process can help ensure policy decisions are seen as being legitimate, thereby strengthening trust.

Developing a strong social contract between government and the governed is no easy task. Healthy scepticism towards politicians is important so that government remains accountable to an active and vigilant citizenry.

Nevertheless, public trust is critical to expanding state capacity for the long run and to tackling future crises, such as climate change.

Where can I find out more?

• Rebuilding trust in government: article from Deloitte Insights on building public trust, with a focus on the United States.
• Trust in public institutions: policy brief by the United Nations Department of Economic and Social Affairs.
• Policymaking, trust, and the demand for public services: Gianmarco León-Ciliotta, Dijana Zejcirovic and Fernando Fernandez show that disclosure of forced sterilisations of women and human rights violations in Peru under Alberto Fujimori decreased trust in public institutions and reduced demand for public health services.

Who are experts on this question?

• Tim Besley
• Chris Dann
• Imran Rasul
• Paola Giuliano

Author: Chris Dann

Photo by f11photo from iStock

The post Does public trust in government matter for effective policy-making? appeared first on Economics Observatory.

Dobbs hands the decision of access to abortion back to individual states. The ruling set in motion a series of anti-abortion legislation – known as ‘trigger bans’ – in a number of states across the country. It is estimated that at least 25 states will move to ban abortion as quickly as possible (Guttmacher Institute, 2022).

This is despite the majority of US adults believing that abortion should be legal in all or most circumstances (61%), according to a recent survey (Pew Research Centre, 2022).

Some of these state laws will prohibit abortions, allowing exceptions only in cases where the life of the mother is at risk or if the foetus has a fatal abnormality (New York Times, 2022). Nevertheless, there have already been reports that restrictive laws may delay treatment for pregnancy complications, putting women’s lives in danger (Texas Tribune, 2022).

Figure 1: US abortion policies and access after Roe

Source: Guttmacher Institute, 2022

In submitting the Dobbs case, the state of Mississippi claimed that ‘there is simply no causal link between the availability of abortion and the capacity of women to act in society’, and thus that access to abortion has not affected ‘the ability of women to participate equally in the economic and social life of the Nation’ (Supreme Court of the United States, 2021).

In reality, the ruling will directly affect the lives of millions of women in the United States and will have a profound impact across society. This is backed up by a large body of research evidence on the impact of abortion access, not only on births but also on the economic wellbeing and health of those who are affected.

This research makes use of the fact that abortion access has varied across US states and compares what happened in states that expanded (or restricted) abortion access with what happened in states where abortion access stayed the same.

For example, five states and one district had already revoked their abortion prohibitions many years before the Roe v. Wade ruling (Myers and Welch, 2021). This allowed researchers to compare changes in outcomes related to fertility, education and wellbeing in the ‘repeal’ states at the point at which they removed abortion restrictions to changes in the rest of the country.

The states in which abortion access did not change act as a ‘control’ to account for alternative confounding effects that may have affected fertility and women’s lives at the time of Roe v. Wade. Using this approach, the researchers can be more confident that they have identified the causal effect of abortion access.

The findings from this research provide evidence that there is a causal link between the availability of abortion and the capacity of women to act in society – and gives an insight into what may happen as a result of the Dobbs ruling in states that ban or further restrict access to abortion.

Who is most likely to access abortion?

In 2020, 930,160 abortions took place in the United States (14.4 per 1,000 women), an 8% increase from three years previously. Accompanied by a 6% decline in births, these patterns indicate that fewer people were getting pregnant and among those who did, a greater proportion chose to have an abortion (Guttmacher Institute, 2022).

Of the 6.1 million pregnancies in the United States in 2011, 2.8 million were unintended, which equates to roughly 45%. Of these, 27% were ‘wanted later’ and 18% were ‘unwanted’ for other reasons (Guttmacher Institute, 2019).

Although these figures convey a relatively high demand for abortions across the US population, there are clear demographic disparities in the incidence of unintended pregnancies. Recognising these differences enables informed decision-making by policy-makers and underlines any inequalities that may be present in the context of abortions in the United States.

These inequalities reflect differences in social, economic, ethical, institutional and political landscapes, which in turn affect women’s choices, abortion access and, ultimately, outcomes related to fertility, education and wellbeing (Guttmacher Institute, 2019).

Traditional estimation methods to find the rate of unintended pregnancy among different groups of women factor in all women in the population, irrespective of whether or not they are sexually active.

Using these methods, rates of unintended pregnancy are found to be highest among women aged 20-24 – 81 per 1,000 women. But when women who are sexually inactive are excluded, the age group with the highest rate of unintended pregnancies is 15-19 year-olds (Finer, 2010).

Cohabiting women have a higher rate of unintended pregnancy – at 141 per 1,000 women – compared with unmarried non-cohabiting women – 36-54 per 1,000 women – and married women – 29 per 1,000 women (Finer and Zolna, 2010). In 2016, over half (59%) of women who had abortions already had a child (Guttmacher Institute, 2016).

Non-Hispanic black women are more than twice as likely to have an unintended pregnancy – 79 per 1,000 women – than non-Hispanic white women – 33 per 1,000 women (Finer and Zolna, 2010).

Three-quarters of abortion patients in the United States are poor or low-income, and nearly half live below the US federal poverty line (Guttmacher Institute, 2016). This is striking as only one in seven women aged 15-44 (the childbearing age range) in the United States live in families with incomes below the federal poverty line (March of Dimes, 2022). 

Figure 2: Abortion patients who are poor or low-income

Source: Guttmacher Institute, 2016

It follows that ease of access to abortion services may be an important determinant of the trajectory of women’s reproductive, economic and social lives. 

How does abortion access affect women’s reproductive, economic and social outcomes?

Birth rates

Using the analytical method discussed above, one study estimates that legalising abortion (Roe v. Wade) resulted in a 4-11% reduction in births in the repeal states relative to the rest of the United States. It showed that the effects on fertility were around three times greater for adolescents and women of colour (Levine et al, 1999).

Further research indicates that legalising abortion resulted in a 34% decline in the number of women who become teen mothers, with even larger effects for black teenagers (Myers, 2017).

Researchers have also looked at the effect of practical restrictions on access to abortion in the United States, particularly variations in travel distance as a result of facilities closing. This work suggests that, on average, a travel distance increase from 0 to 100 miles cuts abortions by 20.5%, consequently raising births by 2.4%. An increase from 100 to 200 miles lowers abortion rates by 12.7% and increases births by 1.6% (Myers, 2021).

Other studies also show that travel distance is a significant factor in seeking abortion among all ages and ethnic backgrounds, particularly young and black women (Myers, 2021; Venato and Fletcher, 2020; Lindo et al, 2020).

In light of the Supreme Court decision, stricter abortion legislation may also appear in the form of mandatory waiting periods between consultation and procedure. One study finds that requiring two appointments reduces abortions (by 8.9%) and delays those that still occur, causing second-trimester abortions to rise by 19.1%. This also increases births by 1.5% (Myers, 2021). As of June 2022, 27 US states had enforced mandatory waiting periods, 13 of which require two in-person visits (Guttmacher Institute, 2022). 

These outcomes vary considerably across different groups of women. Those in their twenties are roughly three times more likely to be affected by waiting periods requiring two trips than women in their thirties. Similarly, non-Hispanic black women experience greater effects (2.5 times) from providers requiring two trips than non-Hispanic white women (Myers, 2021). County-level data indicate that these results are notably larger in low-income areas and they are amplified by longer travel distances. 

Marriage

Several studies show that having access to abortion delays both first births and first marriages (Myers, 2017; González et al, 2018; Brooks and Zohar, 2021). In particular, abortion access without parental involvement decreases the probability of ‘shotgun’ marriages by approximately 50% among young women, according to US data (Myers, 2017). 

In addition to reducing the number of women who became teen mothers, the legalisation of abortion also led to a 20% decline in teen brides. This effect was larger for black teenagers (Myers, 2017).

A recent study from Israel – where abortion is legal – looked at the effects of expanding free abortion: it found that early unintended parenthood fell by 11-14 percentage points and subsequent marriages dropped by 11 percentage points among young women (Brooks and Zohar, 2021).

Economic outcomes

The Israeli study also found that the expansion of free access to abortion led to a shift from full-time to part-time employment and to better paid part-time jobs among the women who were previously working part-time (Brooks and Zohar, 2021). This could be explained by the reported increase in the share of mothers who entered an academic institution as a result of the policy reform and therefore needed more flexibility.

In addition to higher college enrolment, the researchers also observed increases in post-high school professional training and a higher probability of sitting the Israeli matriculation exam in a given year. Despite the observations being short-term, the study also reports that the new policy resulted in around a 17% increase in annual income regardless of the woman’s employment status (Brooks and Zohar, 2021). 

Research that captures the long-term effects of the 1970s abortion legalisation in the United States on educational attainment, labour market participation and earnings for female adolescents offers similar results.

While the results for white women are minimal or insignificant, increases in the employment rate, high school graduation rate and college enrolment due to the abortion reform are more pronounced among young black women (Angrist and Evans, 2000).

Albeit imprecisely measured, one study finds that access to abortion increased college enrolment by 100%, college graduation by two to three times and employment status by 44% for black women (Jones, 2021).

Another study finds an increase of around 2% in the probability of a woman being employed in states that legalised abortion prior to Roe v. Wade (Kalist, 2004). Again, these results show a particularly strong effect among black women.

Impacts on children

Women’s access to abortion services can also affect the average conditions into which children are born. Although evidence on the effect of abortion access on child abuse and neglect is limited, one study that examines variations in the timing of abortion legalisation across US states following Roe v. Wade finds that the legalisation reduced the number of recorded cases of child maltreatment by approximately 10% for every subsequent cohort (Bitler and Zavodny, 2004). It nevertheless reports an inconsistent relationship between the number of reported cases and abortion restrictions imposed after the legalisation.

Another study finds that a child born due to poor access to abortion would have faced a 50% higher risk of living in poverty, a 60% higher probability of being raised by a single parent and a 40% higher chance of dying before reaching the age of one (Gruber et al, 1999).

This research indicates that abortion access improves overall outcomes of entire generations (Ananat et al, 2009).

Health

As has been highlighted by medical professionals and pro-choice campaigners, safe access to abortion is also vital for women’s health. According to the United Nations, unsafe abortions result in approximately 47,000 deaths every year. These are primarily in developing countries and among members of socio-economically disadvantaged and marginalised populations (United Nations, 2021).

But limiting access, as has happened in the United States, will be likely to increase the incidence of unsafe procedures. Research shows that following Roe v. Wade, pregnancy-related death and hospitalisation due to complications from unsafe abortions plummeted (Cohen, 2009).

Indeed, other research has shown that access to legal abortion reduced maternal mortality among non-white women by 30-40%, although this had little impact on overall or white maternal mortality (Farin et al, 2021).

In addition, a recent study estimates that banning abortion in the United States would lead to a 21% rise in the number of pregnancy-related deaths overall, and a 33% increase among black women (Stevenson, 2021).

Conclusion

Access to abortion directly affects the birth rate and has significant ripple effects on the social and economic outcomes of women and their families. 

The effects – on education, employment and health – are felt more acutely by certain groups. Black, young and poor women are much more likely to be negatively affected by a lack of access to abortion.

Evidence tells us that restricting abortion access – whether through laws or creating financial or other obstacles – can have harmful effects on society’s most disadvantaged women. Conversely, research shows that legalising access to abortion can lead to women gaining higher education levels and better employment.

The Supreme Court decision to revoke Roe v. Wade is both an issue of women’s rights but also of racial and socio-economic inequality.

Where can I find out more?

• How banning abortion affects the economic lives of women: Ones & Tooze podcast from Foreign Policy.
• Reproductive policy: by Caitlin Knowles Myers.
• The economics of abortion: Pitchfork Economics podcast.
• Reversing Roe: 2018 documentary film directed by Ricki Stern and Anne Sundberg.
• What can economic research tell us about the effect of abortion access on women’s lives? Brookings Institution report by Caitlin Knowles Myers and Morgan Welch.
• Planned Parenthood.
• Guttmacher Institute.

Who are experts on this question?

• Caitlin Knowles Myers
• Morgan Welch
• Ana Langer

Authors: Alicja Kobayashi and Madeline Thomas

Photo of Stop Abortion Bans Rally from Wikimedia Commons

The post How will the reversal of Roe v. Wade affect American women? appeared first on Economics Observatory.

On Thursday morning, Boris Johnson agreed to step down as leader of the Conversative Party and renounce his position as prime minister. The news came just 36 hours after Rishi Sunak had resigned as Chancellor of the Exchequer and Sajid Javid quit his job as health secretary.

For a few hours on Tuesday evening, the UK was without a senior minister for either the country’s public finances or its healthcare system. Even now, it is unclear exactly how long Boris Johnson will stay on in a caretaker role, and what the timeline will be for a formal leadership contest. As the cost of living crisis escalates and new Covid-19 cases are rising again, it is a dangerous time for the ship of state to be rudderless.

With the prime minister gone, or at least out of office in any meaningful sense, it seems likely that responsibility will fall to the recently assembled cabinet to deliver the government’s key policies. In terms of healthcare and the economy, both Nadhim Zahawi (the new Chancellor) and Steve Barclay (the new health secretary) face substantial challenges.

There are currently over six million people on NHS waiting lists for planned operations in England alone. Ambulance services and A&E departments are reportedly stretched to their limits. According to the head of NHS England, Amanda Pritchard, the next two years could be even more challenging for the health service than during the height of the Covid-19 crisis.

Over at the Treasury, the new Chancellor must decide how best to respond to soaring energy and food prices, as well as widespread demands for wage increases. Establishing a sustainable plan for how to pay for the long-term costs of the pandemic will also be critical. And with the Bank of England now predicting that inflation could climb to 11% by the end of the year, and the war in Ukraine likely to grind on into the winter, the pressures of the cost of living crisis look unlikely to ease any time soon.

How any new prime minister, the replacement Chancellor and the rest of the reshuffled cabinet respond to these issues will have serious effects on the UK economy. Tough decisions lie ahead – decisions that will have profound implications for the wellbeing of millions of people across the country.

All work and no pay (rise)

One challenge the UK government must face immediately is industrial action. Policy-makers are facing mounting pressure from workers and trade unions, who argue that without wage increases many people will continue to see their living standards fall.

The recent strikes organised by the National Union of Rail, Maritime and Transport Workers (RMT) were criticised fiercely by the government, which warned of an impending wage-price spiral if union demands were met. But RMT members remain adamant that now is the time to support workers by increasing pay, loosening the squeeze on real wages caused by inflation.

Further unrest has followed, with strikes by Stagecoach bus drivers in Merseyside taking place over the weekend. Train drivers in the east of England also walked out for the second time on Saturday, halting over 90% of services on the network. This meant only limited trains from Norwich, Colchester and Stansted Airport to London Liverpool Street were able to run, causing significant disruption in the area.

Rumours are also circulating of further walkouts by staff from Network Rail, British Airways and even the Post Office. And unions representing NHS staff and teachers have warned of industrial action to demand pay rises that keep up with increasing prices.

This is not the first time that the UK government has been tested by the unions. Strike activity in the 1970s – as measured by the number of working days lost – was higher than in any other decade after the Second World War. But comparisons to this period should be interpreted cautiously.

In a piece for the Economics Observatory this week, Jim Phillips (University of Glasgow) argues that ‘false narratives’ of the 1970s, articulated by current critics of trade unions, distort our understanding of the present problems. Then, as now, unions were wrongly portrayed as ‘greedily advancing selfish pay claims’ that cause inflation (the wage-price spiral argument). The fact that their mandate is to protect their members’ economic welfare was – and is again being – overlooked.

So why exactly are workers striking and what might this mean for the economy? Jim argues that the strikes should be seen as a collective response to the broken relationship between employment and economic security. Put simply, having a job isn’t paying for many people right now. According to a recent report by the National Institute of Economic and Social Research (NIESR), rising energy, fuel and grocery costs mean that household bills now exceed household income in 60% of UK homes. The strikes are motivated by desperation not greed, Jim concludes.

This is backed up by reports from charities supporting the most vulnerable. The Trussell Trust distributed more than 2.1 million emergency food parcels in the 12 months to the end of March – an 81% increase from the same period five years ago.

In addition to food banks, the use of hygiene banks is also on the rise, as highlighted by Gemma Williams in another new Observatory piece this week. Many people are struggling to pay for basic toiletries, including sanitary products, indicating a rise in period poverty in the UK.

A fresh start?

In his resignation statement outside Number 10 on Thursday lunchtime, Boris Johnson was keen to remind the public of his government’s strong parliamentary majority. This was built, in part, on glittering economic promises to the British people.

Elected in 2019 on the back of campaign commitments to ‘get Brexit done’, ‘level up’ the UK and create a ‘high-wage, high-skill economy’, the outgoing leader used the opportunity to flag the continued importance of these policy areas.

But whether Brexit is truly ‘done’ remains contentious. In particular, controversies around the Northern Ireland Protocol threaten the stability of the UK’s exit agreement with the European Union.

Real wages continue to shrink as inflation swamps pay growth. Productivity and poor skills remain endemic within the UK workforce. As for tackling regional inequality, the future of the Levelling Up and Regeneration Bill is uncertain after this week’s committee meeting was cancelled. The reason: no ministers.

Whatever happens next, UK policy-makers must respond urgently to the issues at hand. A change of leader – or indeed government – will do nothing to halt rising inflation, improve workers’ productivity, bolster wages or encourage labour unions to call off strikes. Nor is it guaranteed to help fix the economic cracks and political divisions left over from Brexit.

Outside the bubble of Westminster, the economy is in dire need of support. Months of distraction and infighting have pushed many problems to crisis point. Enough, it seems, is enough.

Author: Charlie Meyrick

Picture by DZarzycka on iStock

The post Strike out appeared first on Economics Observatory.

Response strategies over the past two years have been on a spectrum, ranging from the Swedish approach with almost no restrictions to the extreme zero Covid-19 strategies pursued in China and New Zealand.

A global comparison of the different national prevention, control and response strategies can pinpoint lessons that could help to strengthen countries’ preparedness and reaction to future health challenges.

The pandemic has exposed the limitations of healthcare systems that had previously been classified as high-performing and resilient (El Bcheraoui et al, 2020). Surprisingly, an early analysis suggests that none of the traditional pandemic indices – such as the Global Health Security (GHS) Index, the World Health Organization (WHO) Joint External Evaluation (JEE) and a measure of universal health coverage – explain countries’ performance during the Covid-19 pandemic (Haider et al, 2020).

For example, certain countries that scored poorly on the pandemic preparedness assessment – for example, Burundi, the Dominican Republic and the Philippines – experienced relatively low fatality rates in the initial stages of the pandemic (GHS Index).

Conversely, overall, wealthier countries with more healthcare resources faced a greater burden from Covid-19, in terms of fatality rates, than low-income countries with fewer resources.

The Institute for Health Metrics and Evaluation (IHME) estimates that upper-middle-income and high-income countries (48% of the global population) experienced over half (53%) of the total excess deaths from Covid-19, as of the end of September 2021. This is despite higher-income countries having much higher vaccination rates since the vaccine programmes began (National Preparedness Collaborators).

Different countries’ experiences and outcomes during the pandemic have varied greatly, and the reasons remain complex and unclear. This article explores possible explanations for this ‘epidemiological mystery’ (Mukherjee, 2021). It also looks at the experience of the UK in this context, including what has gone right in its response and what can be learned from its own experience and those of other countries.

How can healthcare performance be measured and compared globally?

A commonly used performance indicator that allows for cross-country comparison is excess deaths. The UK Office for Health Improvement and Disparities defines excess deaths as the number of deaths throughout the pandemic that are above the number expected, based on mortality rates in previous years. IHME estimates excess mortality rates for all countries (Wang, 2021). This is shown in Figure 1.

Figure 1: Estimated excess mortality rate (deaths per 100,000), March 2020 to September 2021

Source: IHME, 2021

To control for differences in population size and age structure between places and different points in time, mortality rates and excess deaths rates are normally standardised. As Covid-19 disproportionately affects older people, and high-income countries have bigger shares of older people than lower-income countries, this method has to be applied to compare countries’ performances globally.

It must be emphasised that cross-country comparisons are inherently difficult due to large disparities in the levels of disease surveillance between countries of different income status. Infection detection rates vary from below 0.1% in some countries to 70% in others (London School of Economics, 2022). Testing equipment, capacity and access vary widely between countries, as do hospital and care capacity. This has led to some countries not reporting hospital admissions at all.

As Covid-19 has become more prevalent – due to more infectious variants such as Omicron – the impact of inadequate distinction in reporting between hospital admissions with Covid-19 versus due to Covid-19 has also become more significant (London School of Economics, 2022).

What explains countries’ performance in the pandemic?

Using age-standardised excess deaths, it is possible to identify which countries have performed well and which ones have not over the past two years. But this measure does not shed any light on what explains their performance. The questions we need to ask are: which approaches have saved more lives and should these be used in the next pandemic?

These questions can be explored by evaluating the impact of different government response strategies across multiple dimensions of healthcare systems. These could include governance and financing mechanisms, community engagement, health service delivery, the health workforce, medical products and technologies, and public health functions. It has been proposed that measuring healthcare systems across these characteristics allows an evaluation of their resilience.

Broadly, resilient healthcare systems have the capacity to prepare for, recover from and absorb shocks, while maintaining core functions and serving the everyday and acute care needs of their communities. Research suggests that healthcare system resilience explains why some countries fared better than others during the pandemic (Haldane et al, 2021).

One analysis of 28 national responses to Covid-19 concludes that there isn’t a single silver bullet to ensure a resilient healthcare system that delivers better performance (Haldane et al, 2021). Nonetheless, highly effective healthcare systems are those that:

• Activate comprehensive responses, which consider and address health and wellbeing in conjunction with social and economic considerations.
  • Adapt capacity within and beyond the healthcare system to meet the needs of communities.
  • Preserve functions and resources within and beyond the healthcare system to maintain pandemic-related and non-related routine and acute care.
  • Reduce vulnerability to catastrophic losses in communities, both in terms of health and wellbeing, as well as individual or household finances.

According to this study, well-performing countries followed whole-of-government approaches and established multi-ministry task forces that could facilitate evidence-informed decision-making.

Other researchers have studied conceptual factors using quantitative methods and found contrary results. For example, one study finds that healthcare capacity indicators, such as hospital beds per capita, were not associated with lower infection fatality ratios (Bollyky, 2022).

Instead, it was lower levels of government corruption and greater levels of trust in government and interpersonal trust that were most associated with fewer infections per capita. This has been observed in Denmark, for example, where trust in the government is very high and infection fatality ratios were lower compared with many other countries.

Similarly, using results from the World Values Survey and European Values Study, researchers found that confidence in public institutions is one of the most important predictors of deaths attributed to Covid-19 (Adamecz-Völgyi and Szabó-Morvai, 2021). Greater confidence in public institutions increases compliance with government mandates, such as social distancing and quarantining, which effectively contributes to the control of viral transmission.

This is in line with other studies finding that less government corruption is associated with greater reduction in mobility, and an increase in Covid-19 policies by governments led to reduced mobility and activity (Bollyky, 2022; McKenzie and Adams, 2020).

Research has also shown that countries’ outcomes during the pandemic were affected by a number of risk factors, including:

• The extent of international and internal travel (Russell et al, 2021).
• The socio-demographic profile of a country (Martín-Sánchez et al, 2021) – specifically, that deaths occurred predominantly in older people and people with health risk factors such as obesity or diabetes (Banerjee et al, 2020; Docherty et al, 2020).
• Social norms and behaviours related to greater risk of disease transmission – countries where social norms are ‘loose’ (for example, where there is greater tolerance for rule breaking) were at greater risk of higher rates of infection relative to those with ‘tight’ social norms (Gelfand et al, 2021). Non-pharmaceutical interventions such as mask mandates and physical distancing measures have shaped the impact of the pandemic.
• A country’s prior experience with epidemics – adherence to government mandates and compliance with these measures may be affected by previous epidemic experiences.
• Inequalities in society – in England, people living in the most deprived areas have, on average, an 80% higher risk of dying from Covid-19 (Public Health England, 2020). People in low-income groups, black and Hispanic people and foreign-born populations have been at a greater risk of dying.

How did the UK fare in comparison with global performance?

The UK has had one of the highest death rates (per 100,000 people) from Covid-19 among countries with a population of over 20 million (Haldane et al, 2021).

During the spring of 2020, the UK had the second highest peak in Europe, at 101.5% of deaths above the five-year average (see Figure 2); Spain was the highest at 142.9%. But the UK’s high fatality rate was only observed in the first wave of the pandemic.

Figure 2: Relative age-standardised mortality rates

Source: Office for National Statistics, National Records Scotland, Northern Ireland Statistics and Research Agency and Eurostat
Note: For all countries where data are available, colour coded by whether the highest peak was in spring 2020 or autumn to winter 2020, UK coloured in dark blue

Looking at deaths of people aged under 65 years, the UK had the highest peak age-standardised mortality rate during the spring of 2020 out of all European countries (Raleigh, 2021). Overall, comparing excess mortality estimates in the first year of the pandemic, the UK ranked seventh out of 22 European countries, with only Spain, Belgium and some East European countries having higher rates.

How has the existing healthcare structure influenced the UK’s performance?

The pandemic has shed light on healthcare systems’ strengths and uncovered structural and chronic vulnerabilities. The UK’s National Health Service (NHS) has been applauded for working under centralised leadership and continuing to provide all treatments free of charge. This included the provision of free Covid-19 tests.

But the pandemic has led to workforce shortages in the NHS, as employees faced excessive workload and burnouts. This especially affected staff from ethnic minority backgrounds, the same communities that were among the most vulnerable to the disease more generally. This indicated the severe issue of structural racism in the UK.

Despite a lot of criticism, the UK was exemplary in some areas, for example:

Innovations in service delivery

With additional financial support – of £48.5 billion – existing NHS public service and charity capacities were expanded, and Covid-19 related treatment services were provided to UK residents free of charge. Hospitals’ infrastructure was optimised by redesigning existing space for clinical use and repurposing wards for Covid-19 patients. This led to an increase in critical care capacity from approximately 4,000 to 7,000 beds. General practitioners also collaborated with clinical commissioning groups to provide consultations remotely so that patients could be triaged before appointments.

Supply chain management

Parallel supply chains were also set up to support the NHS system to distribute medical essentials rapidly. For example, exports of essential medicines, such as insulin and hydroxychloroquine, were banned over fears of domestic shortages. Private companies such as brewers contributed to the production of hand sanitisers by taking the alcohol from their production lines to bolster local and regional supply.

Research and technology

Rapid and up to date genomics sequencing and surveillance was set up. There was also fast and effective Covid-19 vaccine development, led by the University of Oxford, which has had an immense global impact. The UK’s widespread vaccination programme has achieved the highest vaccination rates across European countries.

In addition, free one-to-one support sessions with accredited psychologists or mental health experts have been available to NHS staff. A tool kit was also developed by the NHS to encourage conversations in the workplace about mental and emotional health.

What went wrong?

Several critical arguments have been suggested as explanations for the high Covid-19 fatality rate in the UK, including:

• A delayed and inadequate government response, especially at the start of the pandemic (British Medical Journal, 2020). In line with the slow reaction of the global health community, the UK assumed a ‘wait and see’ strategy with the aspiration of achieving ‘herd immunity’.
• The UK’s borders remained mostly open, with no border policies in place for months. Even when introduced, they were unmonitored and relaxed in comparison with other countries.
• There was a lack of clear leadership and messaging and policy – and decision-makers broke their own rules.
• In 2009, the UK created an independent committee – the Scientific Advisory Group for Emergencies (SAGE) – with the aim of facilitating evidence-informed decision-making. It was hoped that the best available scientific research would be translated into policy during the pandemic. But the credibility of this committee was called into question as political involvement was uncovered.
• In the first instance, the government also treated the virus like a bad flu, not taking the warnings from public health experts seriously. This response undermined the early warnings of scientists.
• The UK failed to protect its health and social workers adequately. During the first national lockdown, health and social care workers lacked appropriate personal protective equipment (PPE), and many were exposed to Covid-19 on wards or in care homes. At this time, there was little to no access to testing. Later, the Covid-19 threat level was downgraded so that a lower level of PPE was required to treat patients – a move that has been condemned by healthcare workers (British Medical Journal, 2020).
• Waiting lists built up as elective treatments had to be cancelled or postponed. Ethnic minority groups, people living in deprived areas and women were disproportionately affected by this, linking to the issue of structural racism (Warner et al, 2021; Burns, 2022).

How can healthcare systems prepare for future shocks?

Less pressure on healthcare systems leads to better performance. Strengthening all aspects of healthcare systems is key to increasing a country’s capacity to respond to the next pandemic. This requires a holistic, multi-sectoral approach and investment in innovation. Even though innovative solutions and quick transformations were put in place during Covid-19, not all are necessarily sustainable.

Countries must develop sustainable healthcare systems that are prepared to respond immediately to a pandemic, and avoid relying on emergency responses such as task-shifting (an approach that aims to optimise the use of the existing healthcare workforce by reallocating highly qualified healthcare workers to other positions that often require less training).

To achieve this, more investment is needed and both power and responsibility should be granted to healthcare leaders during health crises (see a more in-depth discussion here). To make healthcare systems more resilient, an analysis conducted across all OECD countries found that an extra investment of around 1.5% of GDP is required. The largest proportion of the invested funds should be allocated to staffing (Health Foundation, 2022).

Covid-19 has shocked healthcare systems globally. We have learnt that epidemiology and infectiology need a task force dedicated to policy questions around effective resource allocation.

The pandemic has also uncovered structural and chronic vulnerabilities of healthcare systems, which need to be addressed by policy and decision-makers at all levels. For example, the sudden disruption of global supply chains for PPE, essential pharmaceuticals (including sedatives, dialysis fluids and neuromuscular blockers) and medical devices (such as ventilators, infusion pumps and laboratory technologies), alongside a surge in demand for these products, led to many countries experiencing supply shortages (EU Expert Group on Health System Performance, 2020). After a decade of austerity in public spending and years of underfunding, local services were left ill equipped to cope with the pandemic in the UK.

As Covid-19 is thought to become a recurrent disease, we must continue to learn about the most effective prevention and control strategies from other countries. A holistic approach addressing issues that are beyond the national healthcare system needs to be considered to prepare for future shocks. This includes the establishment of more robust supply chains, as well as greater investments in other sectors, such as education.

Where can I find out more?

• How to prevent the next pandemic: Bill Gates discusses lessons from Covid-19 and sets out how governments can collaborate with one another, and private companies, to tackle future health crises.
• How are deaths counted? Report from the King’s Fund.
• Covid-19 Stringency Index: An interactive map showing the level of response to Covid-19, including measures such as school closures and travel bans.
• Covid-19 policy tracker 2020 (England only): The Health Foundation’s timeline of national policy and healthcare system responses.
• A global database of Covid-19 vaccination numbers: From Our World in Data – and how these data are sourced is outlined in an article in Nature.
• Resources on racism in healthcare from the British Medical Journal.

Who are experts on this question?

• Azra Ghani
• David Spiegelhalter
• Joelle Abi-Rached
• Christopher Murray

Author: Paula Christen

Photo by Asurobson from iStock

The post How do countries’ responses to the health effects of Covid-19 compare? appeared first on Economics Observatory.

The pandemic has raised questions about how these shocks and the policies to tackle them affect not only the economy, but also our lives in general. For example, some narratives during the pandemic claimed a trade-off between health and lives on the one hand, and the strength of the economy on the other.

But adopting a broader approach to policy will enable us to consider the balance between two interacting systems – the social and the economic – which will involve some trade-offs but also some synergies.

Inflation, unemployment and growth

Conventionally, a number of key economic indicators are used to assess the health of an economy. Growth in real GDP is prominent among them, along with inflation, unemployment and the trade balance.

Although it can be tricky to compare the figures directly because of methodological differences, these metrics are particularly useful for international comparison of economic outcomes. The methodology employed for conventional economic indicators also supports macroeconomic forecasts for the future of the economy, which are needed for setting monetary and fiscal policy.

These traditional indicators of economic health show the shock of the pandemic to the economy in several key spheres. Here, we take a brief look at GDP, unemployment and productivity, before and during the pandemic.

Figure 1: Quarterly GDP growth by country/region

Source: OECD.Stat

Figure 2: Real GDP growth including forecasts, by country/region

Source: OECD.Stat. Note: On 17 March, the OECD published estimates of the economic effects of the Russian invasion of Ukraine. A scenario based on a series of assumptions, including higher commodity prices, resulted in GDP being one percentage point lower in the OECD and globally, compared with previous forecasts (see House of Commons Library, GDP International, 2022).

Figures 1 and 2 show the effects of Covid-19 on GDP growth in all G7 economies. With differences in intensity, the direction of change experienced by these countries is consistent, with an all-round decline in real GDP growth.

The greatest shock appears to have come at the very beginning of the crisis, during the first and second quarters of 2020, when most countries were under strict lockdown measures.

All G7 economies subsequently recovered as GDP grew in the third and fourth quarters of the same year. Real GDP growth stabilised across G7 economies from the end of 2020 and continued throughout 2021. Figure 2 shows that across all these countries, real GDP growth is forecast to slow down during 2022 and into 2023.

In the fourth quarter of 2021, UK GDP grew by 1% compared with the previous quarter (2021Q3). The United States, Canada and Japan grew faster than the UK compared with the previous quarter, at 1.7%, 1.6% and 1.1%, respectively. France, Italy and the euro area grew at a slower rate at 0.7%, 0.6% and 0.3%, respectively. Germany faced a 0.3% decline in real GDP growth in 2021Q4.

In terms of forecasts, the UK’s GDP is predicted to grow by 4.8% in 2022 and 2.1% in 2023. This is the highest expected growth level in 2022, relative to other G7 countries, but the second lowest predicted growth rate in 2023.

Figure 3: Unemployment rate including forecasts, by country/region

Source: OECD.Stat

The unemployment rate has been steady and relatively low in the UK, at around 4% since 2016. This has fallen from 6.2% in 2014 and reached a low of 3.8% in 2019. In comparison with the remaining G7 economies, only Japan (2.4% in 2019) and Germany (3.2% in 2019) have had consistently lower unemployment rates than the UK since 2016.

An unexpectedly high level of job quits was recorded in the United States at the end of 2021. This raised the questions of whether a ‘great resignation’ was taking place following the pandemic (and its effect of having people re-evaluate their lives) and whether the same might be occurring in the UK. The evidence of the latter is currently inconclusive (Wadsworth, 2022).

The United States is predicted to have lower rates of unemployment than the UK in 2022 (3.9% compared with 4.3%) and in 2023 (3.4% compared with 4.2%), with a falling trend. The unemployment rate soared in Canada (9.6%) and the United States (8.1%) with the outbreak of the pandemic in 2020, but it is predicted to fall to almost pre-pandemic levels in the United States (3.4%) and to just above this point in Canada (5.8%) by 2023.

The rates in Japan and continental European countries have been more stable with a declining trend, although it should be noted that the starting rates in France, Italy and the euro area remain significantly higher than other G7 economies, rising from around 1% in 2014 to predictions of around 8% in 2023.

Figure 4: Annual change in GDP per capita

Source: OECD.Stat

Productivity, measured by GDP per hour worked and GDP per capita, is another telling statistic. The impact of the pandemic on productivity across all of the G7 countries is clear.

All economies experienced a decline in GDP per capita growth from the previous year, ranging from the biggest decline in the UK (-9.8%) to the smallest in the United States (-3.9%). Italy and France saw declines in growth of -8.6% and -8.1%, respectively.

The UK’s productivity decline adds to one of the biggest economic policy questions currently facing the country – that of the ‘productivity puzzle’ (Lucas, 2021). By 2021, G7 countries experienced positive productivity growth compared with the previous year.

Wellbeing

These conventional indicators can be useful for drawing certain conclusions. But there is increasing recognition, especially over the last decade, that they do not tell the whole story. In fact, these indicators miss a substantial part of explaining how well the economy is doing.

There are two main related problems. First, these indicators are somewhat ‘narrow’ in the information that they cover, and they omit things that are of interest to assessments of quality of life. For example, the unemployment rate alone does not tell us about the quality of employment, or precariousness within employment.

Second, these indicators risk being seen as ends of policy-making in themselves, while they may be quite detached from our broader wellbeing. GDP, income and employment can all contribute to our wellbeing, but are not necessarily constitutive of it.

These two issues have contributed to a shift in emphasis in policy and academic circles towards a ‘wellbeing economy’, involving multidimensional measures of economic progress and quality of life. Within these spheres of economic study, the aim of policy-making is to achieve individual and social wellbeing.

One prominent approach involves the economics of happiness. This uses a broader and alternative range of indicators to measure and evaluate the progress of an economy. The field is expanding at great pace: the World Happiness Report notes that the term ‘happiness’ is appearing more in texts, and now more often so than GDP (Helliwell et al, 2022). This indicates a shift in values and economic narrative.

Although the domain of happiness economics offers alternative conceptual approaches for analysing and measuring wellbeing, the most integrated into policy design is the ‘subjective wellbeing’ approach. This includes several metrics but is generally based on positive psychology concepts and uses self-reported measures, such as life satisfaction.

Figure 5: Negative affect balance

Source: OECD.Stat, Gallup World Poll

For example, the negative affect statistic represents the share of respondents that report more negative than positive feelings or states compared with the previous day. Figure 5 shows a mixed picture of individual subjective wellbeing in certain countries.

The most extreme valuations are reported in Italy, while those of Japanese and American individuals are the most steady (although Japanese citizens report overall lower levels of negative affect compared with US citizens).

The UK also appears to present a relatively steady level of individual subjective wellbeing, in terms of changes in negative affect. The balance fell between 2016 and 2018, indicating a rise in subjective wellbeing, but the proportion of negative states has continued to rise since 2018. Canada has followed a somewhat similar trajectory to the UK, but since 2017, it has had higher numbers of respondents with a greater proportion of negative feelings and states.

Figure 6: Life satisfaction

Source: OECD.Stat

What about life satisfaction? The comparable data (gathered on two occasions in recent years – in 2013 and 2018), at the European and international level, reveal a slight upward trend in personal assessments of life satisfaction over the five years in Canada, France, Germany, Italy and the UK. The overall level between countries is similar, with the UK faring second best in terms of life satisfaction in 2018 among the five countries.

The risk in this approach is that policy again becomes focused on a single metric, and one that does not vary substantially over time (Agarwala et al, forthcoming). Although national level policy is bound to need a relatively small number of indicators of success, or otherwise, effective policies for wellbeing will require a broader approach. The 2009 Sen-Stiglitz-Fitoussi Commission recommended a ‘dashboard’ involving some conventional economic indicators, and a broader set of metrics speaking to quality of life.

The interest in economic and individual wellbeing measurement has led to a range of approaches that attempt to bridge both objective and subjective accounts of wellbeing.

To this end, several dashboard indicators have been proposed, such as the OECD ‘How’s Life?’ index or the United Nations’ Sustainable Development Goals (SDGs). These dashboards recognise the importance of self-evaluated ‘happiness’ or life satisfaction, but maintain that this is just one element of overall wellbeing.

They also emphasise the need to complement subjective assessments of wellbeing with objective indicators. The danger inherent in dashboards is that they can proliferate indicators (the SDGs have 231 and provide no framework for evaluating trade-offs between them). Nevertheless, they can be helpful in understanding what contributes to individual wellbeing and quality of life.

Finally, official economic statistics are themselves expanding to cover a wider range of indicators of progress alongside GDP growth. The System of National Accounts, promulgated by the United Nations, has already adopted official methods for measuring natural capital and the use of ecosystem resources. It is currently undergoing a major revision that will see other previously ‘missing’ assets – such as health as part of human capital and some cultural assets – being defined and implemented over time.

The diverse country dynamics described above point to the benefit of a balanced overview of multiple important spheres for a context-specific analysis of economic wellbeing, particularly at a time when successive crises – the global financial crisis, the pandemic, Brexit (for the UK) and war in Ukraine – have led many people to question how we should assess economic progress or its absence.

Where can I find out more?

• World Happiness Report 2022.
• The latest international data releases can be found here: OECD Statistics.
• Latest European country data releases can be found here: Statistics | Eurostat (europa.eu).

Who are experts on this question?

• Paul Allin
• Eric Beinhocker
• Diane Coyle
• Jan-Emmanuel De Neve
• Mark Fabian
• John Helliwell
• Richard Layard
• Mary Morgan
• Joseph Stiglitz

Author: Julia Wdowin

Photo by davidionut from iStock

The post How is the UK economy faring compared with other countries? appeared first on Economics Observatory.

Unlike the devolved legislative assemblies in Wales and Scotland, the Northern Ireland Assembly has power-sharing at its core. This means that unionists and nationalists both participate in governing the nation and that cross-community support from both groups is required for legislation to be passed. This arrangement is part of the Belfast or Good Friday Agreement – the 1998 deal that brought a cessation to the long period of violence and instability known as the Troubles.

But power-sharing has its downside. Without agreement from both sides of the sectarian divide, a government cannot be formed, and if one side withdraws its support, the whole government collapses. Since the Assembly’s inauguration in 1999, Northern Ireland has been without a government for nearly eight of the past 22 years. Most recently, the Assembly was suspended from 9 January 2017 to 11 January 2020.

The Northern Ireland Protocol

Brexit has contributed to political instability and tensions in Northern Ireland. The UK’s exit from the European Union (EU) meant that a border check for goods either needed to be on the border between Northern Ireland and the Republic of Ireland or between Great Britain and Northern Ireland.

The latter was chosen, and the Northern Ireland Protocol came into effect in early 2021. The Protocol means that goods coming from Great Britain into Northern Ireland are checked to ensure compliance with the tariff and non-tariff aspects of the EU’s single market and customs union.

The implementation of the Protocol has caused unionist political parties to become vexed about Northern Ireland ’s constitutional position within the UK and is playing a major role in the upcoming election. The main slogan of one unionist party is ‘No Sea Border’. Unionist parties may also be unwilling to form a government with the Protocol in its current guise.

Leaving aside the constitutional question, Esmond Birnie (Ulster University) in his Economics Observatory article this week examines the economic impact of the Protocol. For me, there are two main takeaways from his piece. First, we need much better data to assess the impact of the Protocol and to establish the winners and losers from it. A careful and detailed economic appraisal may help to allay wider concerns. Second, there are several policy options available that could help to reduce the regulatory burden of the Protocol.      

Fixing the NHS

The NHS in Northern Ireland is in a mess. Ciaran O’Neill (Queen's University Belfast) in his piece highlights the extent of the problem. Prior to the pandemic, the number of people waiting over a year for a consultant-led outpatient appointment was 100 times greater in Northern Ireland than in England, despite England’s population being 29 times larger than that of Northern Ireland.

The solutions to fixing the NHS in Northern Ireland have been long known – rationalisation of the hospital sector, better workforce planning, long-term budget setting and sustained investment. So, why haven’t these things happened? Political instability and the design of Northern Ireland’s political institutions mean that politicians have not had a long-term vision for the NHS and do not have the incentives to reform it.

Growing the economy

Productivity is central to growing the Northern Irish economy and it needs to take centre stage in the next government's economic policy. The nation’s productivity is almost 20% lower than the UK average. What needs to be done to close this substantial gap?

David Jordan (Queen's University Belfast) in his article on skills shows how Northern Ireland’s attainment gap and brain drain affect the province’s productivity (Figure 1). The incoming government will need to make this skills deficit one of its top priorities. This will require difficult decisions about inefficient and divided school systems, investment in lifelong learning and improved funding for further and higher education.

Figure 1: Educational attainment of individuals aged 16-64, in 2020

Source: Nomis, ONS Annual Population Survey

In addition to skills, innovation activity is a major driver of productivity. As Karen Bonner (Ulster University) shows in her article, Northern Ireland performs poorly on business innovation activity compared with other UK regions (Figure 2).

Figure 2: Percentage of innovation-active businesses by UK region, 2014-16 and 2016-18

Source: NISRA

Nevertheless, she also shows that Northern Ireland has an advanced innovation ecosystem with high levels of collaboration between innovative small and medium-sized enterprises (SMEs). The incoming government will need to build on and facilitate this. Investment in skills, lifelong learning and higher education will again be important to help the innovation ecosystem to flourish.

Political instability is also playing a role in holding back productivity growth. Instability has meant that the long-term policies that would enhance Northern Ireland’s abysmal productivity performance and lay the foundation for a prosperous economy have been neglected.

The inherent instability of the Northern Ireland Assembly creates uncertainty for businesses – something they seriously dislike. This, in turn, means reduced investment by businesses (Bernanke, 1983; Bloom, 2014), higher costs of capital (Pástor and Veronesi, 2013), reduced business formation (Dutta et al, 2013) and the diversion of entrepreneurs into other activities (Baumol, 1996).

Even if political instability can be addressed, politicians in Northern Ireland have no incentive to grow the province’s economy because they have no skin in the game. The Northern Ireland Assembly gets a block grant from Westminster and simply allocates it among the various government departments. If fiscal powers were devolved, then politicians would have a strong incentive to grow the economy and the tax base.

A plea for stability

Political stability and well-designed political institutions are foundational for a successful economy. Politicians in Northern Ireland, Ireland, the EU and the rest of the UK need to make political stability their number one priority.

The political institutions created under the Good Friday Agreement need to be refreshed so that Northern Ireland’s government cannot be so easily collapsed when one community does not get their way. Alternatively, power could be handed over to publicly accountable technocrats to run public services such as health and education and skills. This may create a democratic deficit, but the health of Northern Ireland’s economy and its population may well warrant it.

More importantly, as highlighted in a video released by the Financial Times this week, political stability is of paramount importance for the youth and divided communities of Northern Ireland.  

Author: John Turner, Queen’s University Belfast and a lead editor of the Economics Observatory

Photo by Anthony Boulton on iStock

The post Northern Ireland’s election appeared first on Economics Observatory.

A broad consensus on the key issues has emerged from these reviews. There is an over-abundance of – and excessive reliance on – hospital-provided care in Northern Ireland. The healthcare system requires more effective performance management, greater strategic workforce planning and changes to the level and period over which funding is provided to facilitate a more strategic approach to service planning and delivery.

The symptoms

The Northern Irish healthcare system is arguably as well funded as in other parts of the UK. But statistics on its performance are stark (O’Neill et al, 2021).

Both waiting list sizes and the waiting time for a first appointment in Northern Ireland are the worst in the UK. For example, in 2019, before the disruption of services caused by Covid-19, the number of people waiting over a year for a consultant-led outpatient appointment was 100 times greater in Northern Ireland than it was in England (allowing for differences in population size).

In December 2021, almost 85% of outpatient appointments breached the ministerial waiting time target of nine weeks, with over 52% of outpatients waiting more than a year to be seen. Further, 81.5% breached the 13-week waiting time target for admission for treatment, with almost 58% of patients waiting more than a year.

Of those waiting for a diagnostic test, almost 57% breached the target of nine weeks with over a third waiting more than 26 weeks (Department of Health, 2022).

Figure 1: Northern Ireland waiting time statistics, outpatient waiting times, quarter ending December 2021

Source: NISRA, 2022

These earlier problems were not the result of Covid-19 pressures, although the numbers waiting for outpatient appointments, diagnostic services and inpatient/day case admission continued their upward trend during the pandemic. For some specialties, such as rheumatology, these average waiting times can conceal much longer waits that can extend up to seven years, effectively amounting to a denial of service.

Outside hospitals, there is substantial evidence that GP services are also facing serious capacity problems. Demand in the community has risen due to population ageing and patients’ needs becoming more complex with rising multi-morbidities (the presence of two or more long-term health conditions).

Since 2014, the number of GP practices in Northern Ireland has actually declined by 8% and the average number of patients per practice grown by almost 14% (Department of Health, 2021).

Worryingly in terms of workforce and service planning – and given the centrality of primary care to the operation of the entire healthcare system – data on the number of GPs in Northern Ireland have not been available since 2003, when the new GP contract was introduced. (Full-time equivalent figures are produced for England.) In the absence of good data, it is hard to understand the current situation, let alone plan for a better one.

On a weekly basis, the media report stories of excessive delays for care, service crises and individual tragedies that are indicative – to paraphrase Sir Liam Donaldson’s assessment in 2014 – of a system with systemic problems throughout, where incidents of harm are distributed largely by chance both by location and type.

A recent pronouncement by a representative of the Royal College of General Practitioners that a telephone triage system adopted by GPs during the pandemic is ‘here to stay’ exemplifies the reactive and crisis-driven nature of change rather than one that is rationally planned and prepared for.

Diagnosis and treatment

So how do we fix this? A broad consensus on some of the fixes exists. The Donaldson and Bengoa reports, for example, echo the much earlier Hayes report of 2001 and set out a compelling case for rationalisation across the hospital sector. This would include the ten acute hospitals that currently serve a population of 1.8 million.

Rationalising services – and in particular elective services – would allow them to be delivered in a more efficient, safe and sustainable manner. It would increase throughput and allow economies of scale to be achieved.

Staff would also work in a safer and more supportive environment, where expertise could be acquired, training provided and a critical mass achieved that would avoid recourse to expensive locums and agency staff. Better working conditions such as these should make it easier to attract and retain staff and avoid expensive staff turnover costs.

With respect to workforce planning, we need data on the demand for and supply of effort. Here, planning models must reflect the multidisciplinary teams in which staff work, rather than the silos in which they train. They should also take account of evolving technology and work practices as well as training lead-times.

But as noted, information on the current situation is essential for future planning. For example, the current GP numbers could be estimated and compared with how many were trained to get a better understanding of how many more we need to train for the future.

Similarly, among consultants, we need to know how many ‘programmed activities’ – units of effort – are actually devoted to treating patients. This would improve understanding of how many are required for projected future needs. As with hospital rationalisation, this seems like a ‘no brainer’ and such information should be readily available for governance in any event.

In addition to how we use resources currently, there is undoubtedly a case for additional funding across the NHS to help fix historic underinvestment during the years of austerity. As noted in a recent Lancet Commission, significant sustained investment in our healthcare services is required. The perverse incentives caused by annual budgets should also be eradicated.

We need to value nurses, doctors, care assistants, social care staff and informal carers without whom the service would collapse. This needs to go beyond applause and manifest itself in real-term pay increases. This would have to come with an acceptance of the consequences for taxes or what other services the state can provide from current taxes (O’Neill et al, 2021).

All of this is largely agreed, so why are we not doing it? The answer is simple: these are political decisions and require political leadership. The hope for change – that successive fundamental reviews have helped to sustain – increasingly, one fears, has facilitated inertia and procrastination among those who lead the service.

Since powers were devolved to Northern Ireland’s legislative assembly, Stormont, in December 1999, it has been suspended on five occasions. The most recent crisis was in February 2022 when the First Minister resigned over the Northern Ireland Protocol. Only an impending election avoided another suspension.

Even when the Assembly has sat, its record in progressing change is far from stellar, as the above record shows. The number of reviews that have arrived at essentially the same conclusions – but produced limited responses – is perhaps indicative of a desire to delay rather than embrace change.

Perhaps in recognition of this, the review by Sir Liam Donaldson in 2014 (which set the stage for the review by Rafael Bengoa in 2016) called for local politicians to commit to the recommendations of an international panel in advance of their delivery with a view to circumventing the braking mechanism that local politics can exert on reform.

In a previous study, we noted that ‘all politicians are aware of the backlash that can be generated by hospital closures and in Northern Ireland, where there are proportionally six times as many as in the House of Commons, any closure would affect a lot of politicians’ (McGregor and O’Neill, 2014). In essence, politicians are unlikely to close a hospital – even if Northern Ireland would collectively benefit from rationalisation – for fear of losing crucial votes.

To make the necessary changes to the health service, Northern Ireland needs to fix its politics and/or how its politics interacts with the health service. In a democracy, this can be done by voting in politicians who serve the population’s interests and voting out those who don’t.

If this is a step too far for Northern Ireland, it may be necessary to take the health service out of the hands of the politicians and develop valid and transparent measures by which those who do lead it can be held to account for its performance.

If neither of these options are pursued, we need to be honest and accept that resources will be wasted, outcomes will be poorer and health disparities will be likely to widen.

Where can I find out more?

• The right time, the right place: The Donaldson review of health and social care in Northern Ireland.

• Securing a sustainable and fit-for-purpose UK health and care workforce: Ciaran O’Neill and colleagues explore the need for improved workforce planning in Northern Ireland’s healthcare system.

Who are experts on this question?

• Ciaran O’Neill
• Carol Propper

Author: Ciaran O’Neill, Queen’s University Belfast

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The health effects of the pandemic are clearly wide-ranging, but they can be categorised into three ‘orders’ (Fisayo and Tsukagoshi, 2021):

• First-order effects. These are the direct effects of the virus: infections, deaths and the condition known as long Covid.
• Second-order effects. These are indirect effects, largely in the short to medium term, stemming from measures implemented to control the pandemic. They include unmet health needs arising from the NHS backlog, and the mental health effects of lockdowns.
• Third-order effects. These are longer-term, indirect effects caused by the impact of the virus on key social influences on our health, particularly employment and education.

This article provides an overview of these effects. It offers insights from public health research that is relevant to decisions on how to allocate resources as, two years into the pandemic, we continue to live with Covid-19 and must find more ways to limit its damage.

While Covid-19 may have affected us all to one degree or another, its impacts have not fallen equally across society. The pandemic has increased health inequalities, creating a wider gap that may take decades to close. These social disparities are highlighted to show how resources could be targeted, but also how moves to reduce inequalities and improve social cohesion will create a more resilient society – and one that is better equipped to cope with health risks of all kinds.

What have been the direct health effects of the pandemic?

On 29 January 2020, the UK confirmed its first positive tests for Covid-19. The patients were a student and his mother who had recently arrived from Wuhan, where the world’s first case of Covid-19 had been confirmed a month earlier.

From January 2020 to late March 2022, there have been 20.6 million confirmed cases of Covid-19 in the UK. In the same period, there have been over 774,000 hospitalisations and 164,000 deaths (within 28 days of a positive Covid-19 test).

Successive waves of infection – driven by new mutations and changes in public behaviour – have been tempered by containment and suppression. This has led to the formation of the now familiar ‘mountain ranges’ of infection, hospitalisation and death rate charts.

Critically, and most notably in the most recent Omicron-dominated wave, we no longer see hospitalisations and deaths reaching the same heights as infection cases (see Figure 1). This is largely thanks to the biggest vaccination programme in the UK’s history.

Figure 1: Covid-19 cases, hospitalisations and deaths

Panel A: Infections – percentage testing positive for Covid-19

Panel B: Hospital admissions – weekly admission rate per 100,000

Panel C: Deaths involving Covid-19 – weekly deaths registered

Source: ONS
Note: Data for England only. The first pink line corresponds to the emergence of the Alpha variant, the second pink line corresponds to the emergence of the Delta variant, and the third pink line corresponds to the emergence of the Omicron variant.

At the end of January 2022, around 2.4% of the UK population (1.5 million people) were living with self-reported symptoms of long Covid (ONS, 2022). Four in ten (45%) of these people had been experiencing symptoms for at least a year after the first (suspected) infection. Around two-thirds (65%) said that their condition adversely affected their day-to-day activities.

There is still much to learn about long Covid. A better understanding of its vast range of symptoms – over 100 have been identified so far (Hayes et al, 2021) – will help healthcare planners to allocate resources between disciplines, whether neurology or respiratory health, for example. It will also inform how they can work together effectively.

Recent findings show that double-vaccinated Covid-19 patients are 50% less likely to develop symptoms of long Covid, compared with the unvaccinated (Antonelli et al, 2022). This is encouraging, and adds to the impetus to get people vaccinated.

What are the social disparities in Covid-19 infections and deaths?

Vaccines are not the only things to offer protective effects against Covid-19. Relative privilege has also limited a person’s chances of infection. It affords greater opportunity to practice social distancing – through working from home, for example – and a lower likelihood of existing health vulnerabilities. As one study notes, ‘socio-economic status (SES) is a matter of life and death when it comes to the way people are affected by the virus’ (Khedmati Morasae et al, 2022).

Some socio-economic groups are at greater risk of catching Covid-19, and of suffering worse effects. The differences reflect patterns of structural inequality that were already present before the pandemic and well understood by both social and health scientists.

To give some statistical examples, UK data show that areas of the country with low deprivation and low ethnic minority populations experienced average Covid-19 rates of 0.369% between June 2020 and Sept 2021, compared with 0.405% in areas with high deprivation and high ethnic minority populations (Padellini et al, 2022). Research also shows that the risk of death involving Covid-19 in the UK was 3.7 times greater for people with a learning disability compared with people of the same age without one (Flynn et al, 2021).

A study of patients with Covid-19 admitted to critical care units in Scotland during the first wave of the pandemic revealed that 24.9% were from the most deprived fifth of the population and 13.6% from the least deprived. Death was 1.97 times more likely for patients from the most deprived fifth (Lone et al, 2021).

Some health inequalities have shifted over the pandemic. The first wave hit ethnic minority populations harder than white British populations. But studies show that by the second wave, risks had dropped for all ethnic minority groups except South Asian communities, even matching those for white British populations (Nafilyan et al, 2021; Mathur et al, 2021; Padellini et al, 2022).

It has been suggested that this may be thanks to the effects of public health messaging in changing behaviour across most of the UK population. But this messaging may not have been well targeted to South Asian groups (Nafilyan et al, 2021).

It was also insufficient to overcome deeper structural issues, such as the higher numbers of South Asian people in public-facing or key worker roles. Among the UK’s South Asian population, 7% are defined as critical workers by the ONS – compared with, for example, 3.3% of the black population (Padellini et al, 2022).

What are the indirect health effects of the pandemic in the short and medium term?

The shift in NHS activity to prioritise Covid-19 patients, as well as government stay-at-home orders and school closures, have been key components of the national pandemic strategy. But these have all added to widening health inequalities. Crucially, they will lead to increases in ill-health and death rates in coming years, for which healthcare providers must prepare.

Mental health

Two years of the pandemic have taken a large psychological toll. Research shows that the number of people with anxiety almost doubled during the first wave, rising from 13% to 24% (Kwong et al, 2021).

Continued monitoring of mental health will be important to help to shape public health responses. For example, data collected by the Covid-19 Social Study reveal a sharp increase in depression and anxiety symptoms over the Christmas 2021 period in the UK, coinciding with the rise of the Omicron variant. This was especially evident among younger people (Fancourt et al, 2022).

Indeed, among all social groups, research consistently identifies young people as having taken one of the biggest hits to mental health. The same is true for other groups whose lives have been most disrupted by the pandemic, including through greater financial uncertainty, job loss or increased childcare responsibilities during school closures. These are all factors that can reinforce one another.

The groups include low-income families, ethnic minority groups, women and parents with young children (Aknin et al, 2022; Banks and Xu, 2020; Kwong et al, 2021; Serrano-Alarcón et al, 2022). The UK Household Longitudinal Study shows that in the early stages of the pandemic, men suffered a 7.5% increase in mental distress compared with the year before. For women, the increase was 13.5%. Bangladeshi, Indian and Pakistani respondents experienced an increase of 18.22% in mental distress.

Warnings have been issued about the longer-term impacts of mental distress during the pandemic on the highly concerning issue of suicide (Paul and Fancourt, 2022). While suicides did not increase over the first year of the pandemic, known risk factors for suicide did. These include unemployment, mental health problems, domestic violence and insufficient access to mental healthcare, which were accompanied by increases in self-harm thoughts and behaviours. Evidence from past crises, such as natural disasters and recessions, indicates that higher suicide rates tend to come after the event.

Policies to improve economic wellbeing can make a difference here. For example, following the global financial crisis of 2007-09, an increase of 1% per capita in government spending to mitigate the effect of financial hardship was associated with a 0.2% decrease in suicides in Japan (Matsubayashi et al, 2020).

The pandemic and school closures have also affected the health of children and adolescents. A UK survey during lockdown found that 53% of girls and 44% of boys aged 13-18 had symptoms of anxiety and trauma (Levita et al, 2021).

Another study estimates that missing a whole six weeks of school could increase behavioural and emotional difficulties by more than one standard deviation – roughly equivalent to children newly exhibiting three or four serious negative behaviours or emotional difficulties (Blanden et al, 2021). The researchers warn that going back to school in itself is not sufficient for children to ‘bounce back’, and that additional support for children’s mental health and wellbeing will probably be needed for some time.

Health behaviours

School closures and other aspects of the pandemic have also affected health behaviours, bringing concerns that worsening diet and exercise habits throughout the pandemic may also increase future demand for healthcare.

But studies reveal a varied picture of health behaviours across the population. The shock of the pandemic has led many people to make healthier choices, for example, exercising more or eating more fruit and vegetables. In a 2020 study of over one million people in the UK and United States, the ZOE COVID project found that around a third of participants gained weight, while another third lost weight, with weight increases more likely among poorer participants (Mazidi et al, 2021).

Schools are an important source of exercise and nutritious food for many children. A study of the health effects of school closures on young children in Wales shows detrimental outcomes for poorer children, who ate fewer fruits and vegetables than before the pandemic. They also exercised less and ate more takeaways than children from wealthier households (James et al, 2021). Excess weight gained by children during this pandemic could be difficult to reverse and persist into adulthood, placing an additional future burden on the healthcare system.

Unmet health needs

Recent data for England show consistent failure to meet NHS targets, including waiting times for treatment, screenings (such as MRI scans) and ambulances (Baker, 2022). This was true before 2020, and while waiting lists have been growing since 2012, they have grown longer during the pandemic.

In July 2021, nearly 6.1 million patients were on the waiting list for consultant-led treatment in England – the highest waiting list in the current time series going back to 2007. In April 2020, treatments involving admission to hospital were 85% lower than the previous year. Activity has since recovered but remains below pre-Covid-19 levels. In December 2021, there were 14% fewer admitted treatments (-1,148 per day) than there had been in December 2019.

Figure 2: Waiting list for hospital treatment

Source: NHS Key Statistics: England, House of Commons Library, 2022

We have also seen a big drop in patients making appointments, perhaps partly due to fear of infection or to avoid putting an extra burden on health services.

A large study found a reduction in primary care appointments for a vast range of health conditions in the months following the onset of Covid-19 restrictions in the UK. The largest reductions were in appointments for diabetic emergencies, depression and self-harm (Mansfield et al, 2021). These findings emphasise the importance of maintaining healthcare access in future public health planning, including potential further restrictions.

School closures also saw fewer opportunities for schools to report suspected cases of child abuse, with child protection medical referrals dropping by 35-50% in the UK (Viner et al, 2022).

Women, black ethnic groups and poorer groups have been most likely to have prescriptions or medication access, procedures, surgery and clinical appointments disrupted (Maddock et al, 2021). This trend could result in existing health inequalities being exacerbated.

Separate analysis finds that in July 2021, 7% of patients on waiting lists for planned hospital treatment in the most deprived areas of the country had been waiting at least a year, compared with 4% in the least deprived areas (Mahase, 2021).

What are the indirect, long-term health effects of the pandemic?

The health effects of the pandemic could be felt for many decades through its influence on the social determinants of health and on the next generation (Fisayo and Tsukagoshi, 2021).

The health impacts of economic downturns are complex, but they typically serve to worsen health inequalities. It is likely that groups that suffer both poverty and poor health will be most affected in the longer term (Banks et al, 2020).

Fortunately, unemployment levels have not been as high as was first feared. But younger people have been affected particularly severely, given the pandemic’s effects on sectors in which large numbers of them work (such as in shops or bars/restaurants).

This is a concern given that youth unemployment can have lasting consequences for anxiety, depression and suicidal thoughts, which persist into middle age (Virtanen et al, 2016). Around two-thirds of 18-24 year olds who have lost work during the pandemic have reported mental health issues (Resolution Foundation, 2022).

Other groups of particular concern include families with young children or where mothers are pregnant. Economic shocks and downturns during pregnancy and early childhood can have lifelong physical health and cognitive effects (Banks et al, 2020).

There are further reasons to be concerned about the health effects of school closures. Education is one of the strongest determinants of health (World Health Organization, 2008), with clear evidence that learning losses lead to long-term reductions in health and life expectancy (Conti et al, 2010). Despite teachers’ best efforts, there will be children who never make up for their months of missed education and could experience worse health over their lifetimes as a result of lower earnings (Fisayo and Tsukagoshi, 2021).

Looking to the future: what are the big healthcare lessons from the pandemic?

In wealthy countries, at least, we can begin to talk about the move from pandemic to endemic (The Lancet Respiratory Medicine, 2022). Yet at the time of writing, cases are rising sharply again, we remain at risk of more serious mutations, and it is unlikely this will be the last pandemic. Research provides several lessons to help policy-makers prepare for and navigate these coming challenges.

Targeting disadvantaged groups

Effective and timely public health and healthcare measures that target the communities at greatest risk are urgently needed to avoid further widening of inequalities (Davies et al, 2021). For example, given the higher concentrations and more lethal effects of Covid-19 infections in more socio-economically deprived areas, additional resources could be deployed to critical care units (Lone et al, 2021)

More resilient healthcare providers

The pandemic has raised big questions about how prepared the NHS was for coronavirus, as well as whether it is sensible for the NHS to be operating at close to full capacity during non-pandemic times. Overall, the evidence demonstrates that in the last decade, the NHS has not been provided with enough public funding to enable it to grow and meet increasing demand for healthcare services. There are widespread calls for more investment to deal with the NHS backlog, including more staff recruitment.

A more resilient society

Strong and resilient health systems are clearly important, but up to 90% of our health is determined outside the health system (McGovern, 2014). A better appreciation of social care, schools, workplaces and local authorities as managers and preventers of ill-health and inequality will also be important.

Furthermore, we will have better public health if these services are better coordinated with one another. For example, the limited role of the state in funding, delivering and regulating social care has contributed to many of the serious challenges faced by this sector during the pandemic, such as the 30,000 more deaths among care home residents than expected in the first half of 2020.

A more resilient economy

To address the health inequalities brought to the fore by Covid-19, we should ‘not pretend we can plaster over them with individually targeted healthcare interventions after the damage has already been done’, as one health researcher writes (Stokes, 2022). Looking to economic interventions will also help to address these inequalities. For example, strategies to reduce unemployment improve health. Even a 1% fall in employment leads to a 2% increase in the prevalence of chronic illness, research from the Institute for Fiscal Studies (IFS) shows (Janke et al, 2020).

More trust

Countries that have performed badly during the pandemic, in terms of infection and death rates, are often those where the government has been initially dismissive or sceptical of new scientific evidence (including the UK). This has contributed to lower public trust in the government response (Haldane et al, 2021).

A study of 177 countries estimates that if all of them could achieve the same level of trust in government as in Denmark (in the 75^th percentile for trust), global Covid-19 infections could have been reduced by 12.9% (Bollyky et al, 2022). If they had all had the same level of interpersonal trust (trust in other people generally) as in Denmark, global infections could be 40.3% lower. And if any further reason was needed to reduce social disparities, low interpersonal trust is highly correlated with income inequality.

The past two years have shown how the health effects of pandemics extend far beyond infections. They have also exposed weaknesses in healthcare and social infrastructure. But importantly, they have also yielded a rich set of lessons that could help to shape a healthier future for all, both during the remainder of the Covid-19 pandemic and beyond.

Where can I find out more?

• ZOE Covid Study: The world's largest study of Covid-19, and nutrition.
• The NHS backlog recovery plan and the outlook for waiting lists: IFS report, February 2022.
• Socioeconomic deprivation and ethnicity inequalities in disruption to NHS hospital admissions during the COVID-19 pandemic: A national observational study.
• Mental health and Covid-19: World Health Organization.
• Double trouble – Exploring the labour market and mental health impact of Covid-19 on young people: Report from the Resolution Foundation.

Who are experts on this question?

• Carol Propper
• Rachel Griffith
• Flavio Toxvaerd

Author: Michelle Kilfoyle

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But some remain sceptical of whether this is the best approach. An important question for those who doubt the usefulness of wellbeing science is whether stated happiness – currently the most common way of measuring a person’s wellbeing – is a reliable measure of their true happiness.

Evidence indicates that this is likely to be the case. Life satisfaction correlates well with relevant measures of brain activity (Urry et al, 2014). It also does a good job at predicting how people will behave. For example, people who are dissatisfied with their job or with a marriage are much more likely to divorce or quit in the future (Idstad et al, 2015; Clark, 2001).

People are also more likely to vote for governments under which they experience higher levels of wellbeing (Ward, 2020; Ward et al, 2020). And negative events or experiences, such as war, lack of freedom and low life expectancy, correlate with low happiness scores across countries (WHR, 2016).

What does past evidence on happiness show?

Last week marked a decade since the first release of the World Happiness Report. The annual report is published by the United Nations Sustainable Development Solutions Network and is focused on monitoring wellbeing, as well as its causes and consequences around the world.

In its first iteration (WHR, 2012), the editors laid out their vision for a world in which happiness is seen as a central goal for national governments. In the ten reports since, empirical evidence has been presented to highlight that happiness is neither too vague nor too subjective a concept to merit this attention. Today, the report plays an important role in measuring global happiness (using the World Gallup Poll data, among other sources), and in monitoring changing trends.

While happiness increased globally up until 2011, it has been falling ever since. But this trend masks large differences in happiness across countries, with clear winners and losers.

For countries that have seen large improvements in their happiness, such as Bulgaria, Romania and Serbia, increases in GDP per capita have played a part. So too have increases in healthy life expectancy and improved perceptions of corruption or of lack of freedom. We also know that some countries, such as Afghanistan, Lebanon and Venezuela, have experienced a large drop in their average happiness, with almost all these countries having been affected by war, famine or deprivation.

There is also significant variation in happiness within individual countries. Three-quarters of differences in life evaluation come from individuals living in the same place, rather than people living in different countries (WHR, 2016). Increasing inequality, both in terms of GDP and happiness, has accentuated the gap between people living in the same areas.

The experiences of unemployment, loneliness or poor mental health are some of the most important predictors of misery, with income and education also playing a smaller role (Clark et al, 2018).

National governments around the world can play a part in reducing misery by designing policies that target its main causes, such as expanding treatment for mental health disorders or investing in programmes that help people to re-enter employment. Policies focused on these issues could both increase happiness levels and decrease happiness inequality within one country – two important measures to watch if people’s quality of life is to improve.

Happiness trends in 2022

Last year’s report dealt almost entirely with the unprecedented impact of the Covid-19 crisis. It shows that people have been remarkably resilient and that global happiness scores have been largely stable despite this unexpected shock (WHR, 2021).

This year’s report (WHR, 2022), released last week, reflects on the nature of a changing world, where people are still adjusting to the post-pandemic reality. New evidence also shows that happiness matters to people more than ever.

A striking finding of the 2022 report is that interest in subjective wellbeing has increased sharply in the last decade. In a meta-analysis of written text over the past 25 years, the authors find that entries associated with happiness have surpassed entries related to GDP, perhaps suggesting that people are increasingly concerned with wellbeing and less focused on standard economic measures of progress.

Turning to the global outlook, while average life evaluations remained relatively stable throughout the Covid-19 crisis, this trend masks the fact that certain groups have fared better than others. For example, the latest report finds a growing gap in happiness between the young and the old – a worrying trend given the impact of the pandemic on the labour market prospects of young workers and on the experiences of those still in education.

But the pandemic has also led to a positive shift in benevolence. This change, seen in all regions of the world, is evidenced by charitable donations, increased volunteering and a willingness to help complete strangers. The pandemic has also emphasised the importance of trust, of strong community ties and of good institutions. Better happiness outcomes are reported in countries that score high on these metrics and where inequality is comparatively low.

Looking to the future and the role of public policy

Recent technological advances have opened new possibilities for reliably measuring and explaining the happiness of people around the world. For example, machine learning techniques now allow researchers to analyse text quickly by looking for certain patterns that they can then categorise. Using this method on social media content makes it possible to record and classify people’s expressed feelings, providing a real-time metric of how wellbeing is changing (WHR, 2022).

In a separate development, new advances in genetics can help to explore the role of genes in explaining differences in wellbeing. Twin studies show that 30-40% of differences in happiness between people are linked to genetic factors, while the remaining differences are determined entirely by environment.

Researchers are working on creating ‘polygenic’ scores for happiness: these aim to group together the genes that determine someone’s predisposition to be happy. Studies to improve our understanding of the interaction between our genetic make-up and the environment in which we live are also underway.

The increased importance that people assign to happiness has also led to governments around the world turning their focus to this issue. Happiness is now recorded on a regular basis in almost all countries.

Empirical methods have been developed to help policy-makers to evaluate how much additional wellbeing any new policy will generate for a given economic cost needed to implement it. In addition, several governments are proposing the use of wellbeing as a criterion to choose between different policies. For example, the Green Book published by the UK Treasury now recognises social wellbeing as the goal of policy and approves of using measures of subjective wellbeing and their monetary equivalent in policy analysis.

Growing inequality, climate change, emerging infectious diseases and the challenges posed by automation are some of the main challenges we face. But all of these problems are also inextricably interconnected with the happiness of the people affected by them. To solve the complex economic and social challenges facing us, governments around the world should ensure happiness is a central factor within policy design.

Where can I find out more?

• The latest World Happiness Report is available on the WHR website.
• World Happiness Report 2021, edited by John Helliwell, Richard Layard, Jeffrey Sachs and Jan-Emmanuel De Neve.
• Word Happiness Report 2012, edited by John Helliwell, Richard Layard and Jeffrey Sachs.

Who are economic experts on this question?

• Maria Cotofan
• Richard Layard
• Jan-Emmanuel de Neve
• Andrew Clark
• John Helliwell

Author: Maria Cotofan

Image by Rawpixel from iStock

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How was the wellbeing of healthcare staff before Covid-19?

Working in healthcare is associated with significant work-related mental health distress. A comprehensive review of physician burnouts (characterised by emotional exhaustion, depersonalisation and diminished feelings of personal accomplishment) highlights high levels of emotional exhaustion across a spectrum of healthcare workers, including medical students, resident doctors and attending physicians in the United States. This pattern applies to both men and women (Eckleberry-Hunt et al, 2017).

But is this simply part of the job? There is a lack of strong evidence, but cross-sectional and correlational data suggest that the inherent stress stemming from working with chronic suffering and patient deaths does not entirely explain this phenomenon (Guest et al, 2011; Firth-Cozens, 2001).

The researchers who conducted the comprehensive review argue that modifiable workplace factors are increasingly associated with physician stress and burnout (Eckleberry-Hunt et al, 2017). These include a lack of work control and work-life balance (Frank et al, 1999; Glasheen et al, 2011; Linzer et al, 2001; Spinelli et al, 2016), and long working hours and irregular shifts (Mansukhani et al, 2012).

Institutional support – or the lack of it – also affects the mental health of medical staff. For example, poor leadership (Shanafelt et al, 2015), poor support staff (Deckard et al, 1994) and lack of financial rewards (Scheurer et al, 2009) all affect healthcare workers’ mental wellbeing.

In addition to workplace conditions, personal factors play a role in physician burnout. Certain personality traits – such as pessimism and perfectionism – are predictive of burnout (Eckleberry-Hunt et al, 2009). Similarly, different coping strategies are effective to varying degrees: for example, taking time out is associated with lower frequency of emotional exhaustion, while concentrating on what to do next is associated with higher frequency of emotional exhaustion (Lemaire and Wallace, 2010). This evidence indicates that the mental health of healthcare workers is affected by factors beyond the nature of the work.

Proposals to improve physician wellbeing – and consequently patient welfare – have therefore focused on workplace changes. These include increasing support personnel, aligning goals between physicians and leadership, and establishing wellness focus groups.

How has the pandemic affected the mental health of healthcare staff?

Covid-19 has intensified mental distress among healthcare workers, including anxiety and depression. A number of surveys across different countries find prevalent mental health issues among healthcare workers during the pandemic.

A global survey covering 2,707 healthcare workers from 60 countries finds self-reported burnout among 51% of the respondents (Morgantini et al, 2020). In a survey of 7,000 doctors in the UK, the British Medical Association (BMA) finds that 41% of doctors reported suffering with a work-related mental health condition, with 29% stating that this had got worse during the pandemic (BMA, 2020).

Similarly, a cross-sectional survey of 595 healthcare workers in Italy finds that working with Covid-19 patients was a risk factor for higher levels of stress (Babore et al, 2020). In Spain too, a survey of 506 healthcare workers, conducted during the period of the highest incidence of cases and highest mortality rates due to Covid?19, shows medium-to-high levels of compassion fatigue and burnout among respondents (Ruiz-Fernández et al, 2020). In another Spanish survey, 39% of respondents reported high depersonalisation and 43% considered that they might need psychological or psychiatric treatment in the future (Martínez-López et al, 2020).

Surveys in other countries (including Turkey, Oman, China and Ethiopia) show a consistent pattern of high levels of mental distress among healthcare workers during the pandemic (Alan et al, 2020; Badahdah et al, 2020; Wu et al, 2020; Yitayih et al, 2021).

Higher workload, feeling pushed beyond training and making life-prioritising decisions are all found to be predictive of burnout (BMA 2020; Morgantini et al, 2020). Whether exposure to Covid-19 patients increases the risk of poor mental health is uncertain (Amanullah and Ramesh Shankar, 2020).

Some studies find that exposure predicts high rates of burnout (Babore et al, 2020; Kannampallil et al, 2020; Morgantini et al, 2020; Ruiz-Fernández et al, 2020). Others find that frontline workers directly dealing with infected patients appear to experience less burnout, in comparison with other healthcare workers who continue to practice in their usual wards (Giusti et al, 2020; Wu et al, 2020).

A lack of institutional support also increases the risk of poor mental health among healthcare staff. During the pandemic, inadequate access to personal protective equipment (PPE) is predictive of healthcare workers’ mental distress globally (Amanullah and Ramesh Shankar, 2020; Morgantini et al, 2020). Further, insufficient mental health resources – which are acknowledged to be needed to support healthcare workers at the institutional level – has been highlighted as an issue(Alan et al, 2020; Amanullah and Ramesh Shankar, 2020; Martínez-López et al, 2020; Morgantini et al, 2020).

Work-related stress can also affect healthcare workers beyond the working environment. The work-life balance of healthcare workers has been adversely affected by Covid-19, and this is strongly correlated with burnout (Morgantini et al, 2020). Fear of transmitting Covid-19 to family members has also affected medical staff and is associated with higher levels of distress (Wu et al, 2020). Further, healthcare workers report not disclosing mental health difficulties or seeking support for fear of stigma (Galbraith et al, 2020; Yitayih et al, 2021). Concerns about being rejected in their local communities because of hospital work also added to mental distress for healthcare workers at the start of the pandemic (Yitayih et al, 2021).

Are there common trends and lessons across countries?

Poor mental health among healthcare workers is a source of concern both for them and the patients for whom they care. Mental distress of medical staff can negatively affect healthcare through absences, as well as leading to lower quality of care provided.

As a result, providing psychological assistance to healthcare workers may be beneficial both for the individuals directly affected and for their patients. Knowledge of the scale of mental health challenges faced by healthcare workers, and their prevalence, is useful for the design of such psychological interventions.

The first repeated cross-country analyses of mental wellbeing among healthcare workers during the pandemic – run in collaboration with six medical institutions in Italy, Spain and the UK – has collected more than 5,000 responses from medical doctors on their mental wellbeing. The survey was repeated at two points (June 2020 and November/December 2020) during the first two waves of the pandemic (Quintana-Domeque et al, 2021).

Across all three countries, this study finds high risks of anxiety and depression symptoms among medical doctors. Italy had the highest rates of reported anxiety and depression symptoms, while the UK had the lowest. Doctors who are women, who are aged 60 or younger, or who feel vulnerable or exposed at work, as well as those reporting normal or below-normal health, are at particularly high risks. Across time, the study finds no differences in mental health between June and November/December 2020, highlighting a persistent trend in the first and second waves of Covid-19.

These findings are consistent with other studies conducted individually in Italy (Conti et al, 2020, 2021), Spain (Alonso et al, 2021) and the UK (Greene et al, 2021). They are also consistent with existing knowledge on mental health risk factors among healthcare workers – for example, women and those with underlying health conditions being at higher risk (De Kock et al, 2021). The findings from this survey also mirror existing research showing the negative effects of concerns about workplace safety (Cai et al, 2020; Yin and Zeng, 2020) and exposure to Covid-19 (Lai et al, 2020; Lu et al, 2020; Wang et al, 2020) on mental wellbeing.

Are any groups or countries particularly affected?

The study measures risks of anxiety using the Generalised Anxiety Disorder Assessment (GAD-7), and risks of depression with the Patient Health Questionnaire (PHQ-9) (Quintana-Domeque et al, 2021).

Figure 1 shows the prevalence of moderate/above-moderate anxiety (GAD-≥10) and depression (PHQ-9≥10) among medical doctors in Spain, Italy and the UK and over time. In June 2020, the prevalence of anxiety (panel A) was higher in Italy (24.6%) than in Catalonia (15.9%) and the UK (11.7%). At the same time, rates of moderate/above-moderate depression (panel B) were highest in Italy (20.1%), second highest in Catalonia (17.4%), and lowest in the UK (13.7%).

There were no significant differences in the prevalence of anxiety and depression across the two rounds of the survey in any of the three countries, suggesting that the mental health repercussions of the pandemic among medical doctors might be persistent.

Figure 1: Prevalence of anxiety and depression symptoms by country over time

(A) Anxiety

(B) Depression

Source: Quintana-Domeque et al, 2021

Note: Grey bars correspond to Nov 2020 for Catalonia and UK, and to Dec 2020 for Italy. Anxiety symptoms = 1 if GAD-7 ≥ 10 and depression symptoms = 1 if PHQ-9 ≥ 10. 95% confidence intervals.

Women, those aged under 60, those who feel more exposed to Covid-19 at work and those reporting normal or below-normal health all face higher risks of both anxiety and depression. Figure 2 shows the differences in the prevalence of moderate/above-moderate symptoms of anxiety and depression among medical doctors by sex and age across countries.

In all three countries in the study, rates of moderate/above-moderate symptoms of anxiety (panel A) and depression (panel B) are higher among women than men. Similarly, younger respondents are more likely to report moderate/above-moderate symptoms of anxiety (panel C) and moderate/above-moderate symptoms of depression (panel D).

Figure 2: Prevalence of anxiety and depression by sex and age across countries

(A) Anxiety by sex

(B) Depression by sex

(C) Anxiety by age

(D) Depression by age

Source: Quintana-Domeque et al, 2021

Note: Grey bars are for women (panel A and B) and over 60 (panels C and B). Anxiety symptoms = 1 if GAD-7 ≥ 10 and depression symptoms = 1 if PHQ-9 ≥ 10. 95% confidence intervals.

What support is required and what support is available?

Figure 3 shows perceptions of workplace safety and exposure to Covid-19. Around half (50.1%) of Italian respondents did not agree with the statement ‘my workplace is providing me with the necessary PPE’ in June 2020 (panel A). This fell to 30.1% in December 2020, showing a relatively large improvement in safety measures.

In Catalonia, the percentage was 25.8% in June 2020 and 15.4% in November 2020. In the UK, 16.1% of respondents disagreed with this statement in June 2020 and only 10.1% respondents disagreed in November 2020. The percentage of respondents who agreed with the statement ‘I feel vulnerable and exposed at work’ remained constant between rounds. Italy has the lowest rates of perceived workplace safety, as well as the highest rates of anxiety symptoms.

Panel C reports information on the share of respondents that ‘directly looked after Covid-19 patients last week’. This percentage increased between June and November 2020 in Catalonia and rose strongly in Italy between June and November 2020, from one fourth to over half of respondents (58%). Panel D shows that one in five respondents in Catalonia were aware of at least one Covid-19 death among healthcare workers in their workplace in both June 2020 and November 2020. In Italy, this ratio increased from 31.4% in June 2020 to 40.6% in December 2020. In the UK, it remained relatively stable at around 40%.

Figure 3: Perceptions of safety and Covid-19 exposure in the workplace

(A) Do not have necessary PPE

(B) Feel vulnerable and exposed

(C) Directly treat Covid-19 patients

(D) At least one Covid-19 death at workplace

Source: Quintana-Domeque et al, 2021

Note: Panel A: Percentage of respondents who did not agree with the statement ‘my workplace is providing me with the necessary Protective Personal Equipment’; Panel B: Percentage of respondents who agreed/strongly agreed with the statement ‘I feel vulnerable and exposed at work’; Panel C: Percentage of respondents who ‘directly looked after COVID-19 patients last week’; Panel D: Percentage of respondents who were aware of ‘at least one Covid-19 death among healthcare workers in their workplace’.

It is clear that the pandemic presents serious consequences for the mental health of healthcare workers across countries. They have been directly involved in the management of Covid-19 patients since the beginning of the pandemic, and institutional support is vital to address the challenges they face – from access to protective equipment to improved working arrangements. Making mental health resources readily available and encouraging healthcare workers to seek help should be an essential component of institutional support.

While the wellbeing of healthcare professionals clearly needs to be a policy goal in and of itself, policy-makers should note that supporting healthcare workers also benefits society as a whole. Healthcare workers’ mental health and perceived support will also affect their performance, their attitudes towards their patients as well as their likelihood of leaving their jobs – all of which are crucial variables in fighting the current and future pandemics.

Where can I find out more?

• Anxiety and depression among medical doctors in Catalonia, Italy, and the UK during the COVID-19 pandemic: Study by Quintana-Domeque et al, 2021
• British Medical Association (BMA) report on the impact of Covid-19 on doctors’ wellbeing
• Review article on the impact of COVID-19 on the mental health of healthcare workers
• NHS blog article

Who are experts on this question?

• Climent Quintana-Domeque
• Eugenio Proto
• Anwen Zhang
• Michele Battisti
• Ines lee
• Antonia Ho
• Jodie Eckleberry-Hunt
• Luca A. Morgantini
• Johannes H. De Kock

Authors: Climent Quintana-Domeque, Eugenio Proto, Anwen Zhang, Michele Battisti, Antonia Ho and Ines Lee

Photo from iStock

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