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THE PUBLIC HEALTH CARE SYSTEM IN SPAIN
The Spanish public health care system was organised at the beginning
of the eighties, on the lines of the NHS in UK. Its development,
an essential aspect of the welfare state in European countries, was only
possible here in Spain with the fall of the dictatorship following the
death of Franco. It coincided with the neoliberal offensive, led by Ronald
Reagan and Margaret Thatcher, aimed at undermining public systems in order
to open business opportunities to the private sector. This unhappy coincidence
shaped and limited the scope of the Spanish health care service.
The Spanish health care system is founded on the principles of universal
coverage, equity of access, tax based funding, redistributive character,
being free at the point of use, and integrated health care. Planning and
decentralisation of the responsibilities are two substantial elements
to add to the main principles.
MAIN PROBLEMS OF THE SPANISH HEALTH CARE SYSTEM
Funding deficiency
Following the neoliberal paradigm, the conservative Government of José
María Aznar (Popular Party) from 1996 to 2004, established a policy
of containing public expenditure which led to Spain becoming
the country with the least growth in public health care spending among
the developed European countries (EU-15). Consequently, private health
expenditure showed important increases along this period, from 26% of
the total in 1996 to 30% in 2004.
Two important facts occurred in 2002: complete decentralisation by means
of devolving responsibility for health care to the seventeen autonomous
communities and a change of the funding model. Up to then, funding came
from direct taxation, collected at central level and then distributed
among the autonomous communities, according to their populations. From
2002 onwards, funding comes also from indirect taxation, devolved to the
autonomous communities and charged on economic activities and the purchase
of goods and services. The government justified that by saying that it
would stimulate the taxing co-responsibility of the governments of the
autonomous communities. This new funding model has created problems of
funding deficiency, because the magnitude of these indirect taxes depends
on the economic activities and the development attained by each community.
Actually it has increased the inequities in health care and reduced the
redistributive character of the public health care system.
Another factor with a direct influence on the funding is the very high
pharmaceutical expenditure (24% of the total health expenditure, compared
to a mean of 15% at the EU-15). This is the consequence of the government’s
lack of interest in limiting the pressure of the drug companies on the
prescribing physicians and the very limited development of generic drugs.
The increase in pharmaceutical expending has actually moderated over the
last three years from 11-12% per year to 5,6%, but it continues to be
excessive. The main reason for this is the absence of will on the part
of the Ministry of Health (responsible for the regulation of pharmaceutical
policies) to introduce rationalising measures, such as refusal to fund
with public resources the new and more expensive drugs that do not have
demonstrated advantages over the pre-existing ones, or to control the
pressure mechanisms that the drug industry exerts on doctors.
The advance of privatisation
Privatisation made important advances in several ways during the period
of conservative government.. For example, companies contracting complementary
private insurance for their workers benefited from tax advantages. Some
public hospitals became financially managed like private companies by
means of transforming them into “Health Care Foundations”
in several communities (Galicia, Madrid, Asturias, the Balearic Islands,
la Rioja, and Aragón). Hospital Trusts (“Consorcios Hospitalarios”)
with mixed public and private funding were created in Catalonia. The provision
of health care, including both primary and hospital care, was put into
the hands of private insurance companies in one area of Valencia. In spite
of the negative results reported from the UK, PFI has been used to build
and run new hospitals.
The results of these “experiments” have not been beneficial
to the system nor to the users of it. The Foundations with private management
models have all failed to achieve the claimed efficiency improvements,
but have on the contrary increased expenditure and, at the same time,
reduced their facilities and activity. Building has not been completed
in time in the case of hospitals built on the PFI model, and their costs
are much higher than those of the traditionally funded public hospitals.
The first “experimental” Hospital Foundations were established
in Galicia. Now a progressive government (Socialist Party together with
a Nationalist Party) is in power there. In view of their negative results
and the unease that they have induced among the citizens and the health
workers, it has been decided to return these hospitals to the traditional
management model.
Fragmentation of the system
As previously stated, the devolution process has transferred responsibility
for Health Care to the autonomous governments, and therefore seventeen
Health Care services have been created. They are widely autonomous and
enjoy full capacity to establish their regulations, their organisation,
and their functional structures. In principle it was expected that this
process of decentralisation would lead to a more rational use of resources
according to the needs and the problems of every community. However, instruments
safeguarding the cohesion and adequate funding of each community service
have not been implemented. As a consequence, inequalities in health care
are now greater, the system is fragmented into several detached and independent
compartments, and the privatisation of some parts of public health care
has become easier. Unfortunately, this fragmentation prevents the whole
Spanish population being aware of the advance of privatisation and avoids
a global response against it, which would be politically damaging for
the government.
Professional concern
The restrictions in the national budgets together with the growing pharmaceutical
expenditure have led to a reduction of expenditure on staff (number
of contracts and salaries). This fact together with an absence of any
incentivising staff policy, and the deterioration of the working conditions,
implemented in order to reduce the costs, have generated strong professional
concern. More than 5,000 young doctors and nurses have emigrated, the
system having been deprived of young elements that would ensure its renewal.
“Burnout” has become widespread, and the repeated and frequent
strikes reflect the enormous amount of unease built up amongst the professional
staff.
Primary Health Care
Primary Health care is considered the basis and axis of
the whole system by the General Health Care Law, and enjoys a well known
international prestige (recently, Prof. Barbara Starfield affirmed that
it was one of the most developed and efficient in the world). Nevertheless,
shortage of funding (less than 13% of the total health care budget), limited
resources and equipment, a great number of people assigned to every doctor,
and difficulties experienced by doctors in ordering diagnostic tests are
inducing serious problems of quality and of ability to solve the problems
of patients. A significant proportion of the waiting lists and disorganisation
of hospital care could be so explained. Many patients who could be actually
diagnosed and treated at this primary care level have to be referred to
the hospitals. Teaching activities and research have not attained the
expected development, as a consequence of the shortage of staff and resources.
Waiting lists and saturation of the hospital emergency departments
These are probably the problems that are producing most
unease and worry amongst the population and health workers. The cause
of this situation is, of course, multifactorial. The limited ability of
the primary care teams, the deficit of acute (40% less than the average
in the UE-15) and long-term hospital beds (which hardly exist in the public
sector), together with the low productivity and poor management of the
centres may partially explain it. Health care consumerism and the “medicalisation”
of the population, may also be responsible for this state of affairs.
In summary, Spain, like the UK, has a good health care system. Nevertheless,
the policies of expenditure reduction and privatisation promoted by very
powerful financial lobbies, with a great influence on governments, are
contributing to a progressive deterioration in our service in an accelerated
manner, with the risk of its disappearance in the medium term.
Manuel Martín-García, Secretary, FADSP (Federación
de Asociaciones para la Defensa de la Sanidad Pública)
Translation: Diego Reverte-Cejudo
22/2/2008
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The NHS Consultants' Association
