Spain has been a parliamentary monarchy since 1978. Political devolution to regional governments has been incrementally implemented over the last 30 years. Thus, the political organization of the Spanish state is made up of the central state and 17 highly decentralized regions (termed Comunidades Autónomas, that is, autonomous communities, ACs) with their respective governments and parliaments. With a population of 46 661 950 (1 January 2009), Spain covers 505 955 km2 and has the third largest surface area in western Europe.
The fertility rate is one of the lowest in the EU (1.4 children per woman in 2007), showing a timid upward trend compared to the rates registered up to early 2000s. The inflow of migrant population, especially in the last decade, has had a demographic impact in rejuvenating a population that is otherwise rapidly ageing. Life expectancy in Spain is one of the highest in Europe: 82.2 for women and 77.8 for men in 2007.
The top three causes of death in Spain since 1970 have been: cardiovascular diseases, cancer and respiratory diseases, albeit there has been a steady decrease in the actual mortality rates from these causes. Still, mortality rates for these causes are among the lowest in the WHO European Region. Maternal and child health indicators (neonatal, perinatal and maternal mortality rates) have experienced a dramatic improvement, current rates scoring below European averages.
Regarding lifestyle factors affecting health status, the proportion of daily smokers has been declining, though regular alcohol consumption is quite widespread and hazardous drinking affects some 7% of men and 3% of women. Obesity and overweight is increasing, doubling the 1987 rate for adult population to reach 15.6%.
The statutory SNS is universal coverage-wise (including irregular immigrants), funded from taxes and predominantly operates within the public sector. Provision is free of charge at the point of delivery with the exception of the pharmaceuticals prescribed to people aged under 65, which entail a 40% co-payment with some exceptions. Health competences were totally devolved to the regional level (ACs) as from the end of 2002; this devolution resulted in 17 regional health ministries with primary jurisdiction over the organization and delivery of health services within their territory. The ACs’ financing scheme promotes regional autonomy both in expenditure and in revenue raising (especially after the 2009 revision). The national Ministry of Health and Social Policy (MSPS) holds authority over certain strategic areas, such as pharmaceuticals’ legislation and as guarantor of the equitable functioning of health services across the country. The highest body for SNS coordination is the CISNS, comprising the 17 regional ministers of health, chaired by the national minister. Decisions in the CISNS must be adopted by consensus and, as they affect matters that have been transferred, they can only take the form of recommendations.
The typical structure of regional health systems consists of a regional ministry (Consejería de Salud) holding health policy and health care regulation and planning responsibilities, and a regional health service performing as provider. The regional ministry of health is responsible for the territorial organization of health services within its jurisdiction: the design of the health care areas and basic health zones, and the degree of decentralization to the managerial structures in charge of each. The most frequent model consists of two separate executive organizations, one for primary and one for specialist care (ambulatory and hospitals), at the health area level. Nevertheless, regional health services are increasingly creating single-area management structures integrating primary care and specialist care. Basic health zones are the smallest units of the organizational structure of health care. They are usually organized around a single primary care team (PCT) which exercises the gatekeeper function. Regarding patient choice, the possibility to choose a specialist and hospital is relatively less developed (with some differences across ACs), compared to primary health care. In any case, access to specialist care requires referral from a general practitioner (GP). Public health responsibilities tend to be centralized in the regional department of health, though functionally following the basic health areas structure. Each health area should cover a population of no less than 200 000 inhabitants and no more than 250 000.
The non-profit-making private sector plays a key role regarding care for work injuries and professional diseases. There are a number of mutuality schemes covering these contingencies which are funded by the national social insurance treasury, largely through employers’ contribution.
In addition, the public system has traditionally contracted out some 15–20% of specialized care provision to private hospital providers (profit-making and non-profit-making). This contracting out typically buys some high-resolution diagnostic services or outpatient surgical procedures as part of waiting list management.
Private voluntary insurance (PVI) schemes play a relatively minor, though increasingly relevant, role within the Spanish health system. PVI is independent from the public system (opting-out is not possible) and complementary in nature (mainly to gain access to services for which there are waiting times in the public system, such as specialist care, or to access services such as adult dental care, which are limited within the benefits package). Schemes cover some 13% of the population, though there is considerable regional variation.
There is a notable exception to the general scheme outlined: the three mutual funds Mutual Fund for State Civil Servants (MUFACE), General Justice Mutual Company (MUGEJU) and Social Institute for the Armed Forces (ISFAS) cater exclusively to civil servants in government departments and their beneficiaries (4.8% of the population). They are financed from a mix of payroll contributions and taxation. Civil servants are the only group eligible to opt out of the SNS, choosing fully private provision.
Health expenditure in Spain has followed the upwards international trend, reaching US$ 2671 purchasing power parity (PPP) per capita and 8.5% of gross domestic product (GDP) in 2007; it is still below the European average. Most of the health expenditure (71%) relies on the public sector (sourced mainly from taxation); the share of private insurance expenditure amounts to 5.5% and OOP payment spending has moved slightly downwards towards the current 22.4%. OOP covers mainly co-payment for prescriptions for the population under 65 years old, as well as adult dental care and optical products.
Public health expenditure breaks down into 54% for specialist care (inpatient and outpatient) 16% for primary health care, 19.8% on pharmaceuticals and 1.4% on prevention and public health. All these expenditure items have grown over the last decade, though to differing extents; notably, the annual growth of pharmaceuticals expenditure has experienced a deceleration.
ACs administer 89.81% of the public health resources, central administration spends 3% and 1.25% corresponds to the municipalities. Health care is the foremost policy responsibility of ACs. On average it accounts for 30% of ACs’ total budget.
Currently, almost all public health care expenditure (excluding civil servants’ mutual funds) is funded through general taxation. Taxation provides 94.07% of public resources; payroll and employers’ contribution to the work injuries and professional diseases mutuality schemes amount to 2.53% of health funds; the mutual funds catering for civil servants account for 3.4% of the resources.
From 2002 onwards, health care financing has been covered by regions out of their general budgets; transfers from the central state are not ear marked. The system includes several specific funds aimed to cover the estimated expenditure needs in each AC and compensate for uneven investment needs and levering inequalities across regions. The allocation formula is based on a per capita criterion, weighted by population structure, dispersion, extension and insularity of the territory.
In addition, health ear marked funds were created or expanded to cover certain expenses in order to foster the implementation of policies aimed to increase efficiency and to reduce inequalities across the SNS. It applies, for instance, in compensating regions exposed to cross-border health care issues.
Regulation and planning
The basic regulation for the SNS emanates from the 1986 Health Care General Act and the 2003 SNS Cohesion and Quality Act. Subject to this framework, regional governments usually divide their functions regarding health between health authorities, i.e. the regional health ministry and the regional health service. Normally, apart from being the health authority, the health ministry holds responsibility for regulation and strategic planning (including health care planning), while the regional health service is responsible for operational planning, management of the services network and coordination of healthcare provision.
Most of the SNS providers are within the public sector and the predominant governance model has many elements of direct management. The main tool of this model is the contract-programme, which works as management by objectives, incorporating incentives to reinforce certain strategic lines. There is no stated penalty derived from failure to achieve objectives, nor a real transfer of risk to the providers. Some positive financial incentives derived from accomplishment of certain strategic goals (for example, rational prescription, use of generic drugs, reduction of waiting times for certain procedures, etc.) are at stake for teams and eventually for individual professionals; even so, they are always marginal to the bulk of remuneration.
Besides this prevailing model, there are some other forms of provider governance still under direct management but which allow for a legal personality differentiated from the regional health service. All these direct management formulas can be placed in a gradient based on the regimes of contracts, staff and budget; on one extreme would be the strict constraints imposed by the public administrations law while the other end of the range corresponds to private- firm-like frameworks subject to private law (though the property may remain public and the mission of the organization is still public service), laying out the whole range of formulas for the regional governments to choose. In addition there are some indirect management or contracting-out formulas which, in most of the ACs, are confined to the provision of complementary diagnostic tests and ambulatory procedures, and to ancillary services such as hospital catering, laundry, maintenance, cleaning and security. Some ACs have experimented with private finance initiative (PFI) formulas, implementing within their territory the administrative concession to a corporation or a temporary union of enterprises of the provision of care to an entire basic health area. In other cases, the experiment has the features of a classical PFI for hospital building.
Physical and human resources
The primary care network is entirely public and most of the providers are salaried professionals within the public sector with the few exceptions described (private providers are contracted out to provide primary health care under different formulas in Valencia and Catalonia). Primary health care centres are attended by a multidisciplinary team composed of family doctors, paediatricians, nurses and social workers; some can include physiotherapists and dentists’ surgeries, and are linked to some basic laboratory and image diagnosis resources, either in the same premises or centralized and serving several centres in the vicinity. There are a total of 13 121 primary health care centres that serve 3523.3 citizens each on average.
Around 40% of hospitals belong to the SNS; the remainder are privately owned, though many are included in the networks of public utilization or within a substitute concession by which their activity is publicly funded (around 40% of private hospitals’ discharges in Spain are funded out of the SNS budget). The total number of hospital beds amounts to 160 981 or 3.43 beds per 1000 inhabitants; 71.2% of the available beds are functionally dependent on the public sector. Overall, some 40% of total bed capacity is concentrated in big high-tech hospitals of over 500 beds (mainly public); every AC has at least one of these centres, with variations subject to access considerations, such as levels of population dispersion and volume. Over the last two decades there has been a dramatic decrease in psychiatric beds while the number of long-term care beds has experienced some increase. The SNS manages 80% of the acute beds pool, as against only 36% of psychiatric beds and 30% of long-term beds. This points to a shift towards the private sector when it comes to installed capacity for this type of care. The number of acute beds per 1000 inhabitants has also declined in line with the trend observed in other European countries. One of the factors affecting this reduction in acute beds is the progressive introduction of day care substituting for inpatient stays for certain surgical procedures, chemotherapies and dialysis among others.
Investment in information technology (IT) has accelerated in recent years. One of the actions within the line of development of digital public services is the programme Health Care Online (Sanidad en línea). The programme has allowed for co-funding of the ACs’ IT infrastructure and developments, as well as for the progress of the SNS central node of information, making possible the implementation of the SNS unique patient identifier and electronic health record.
As in most European countries, the numbers in all categories of health professionals per 100 000 persons have increased over time; it is worth noting the expansion in Spain of certain profiles, such as nurses, dentists or pharmacists (which have multiplied several times over their availability in the context of a growing population), compared to the relative stability of physicians. This phenomenon reflects well how those professionals’ role has grown within the range of services offered. The population served by primary health care professionals is on average 1410 persons per GP, 1029 per paediatrician and 1663 per nurse. Available workforce per 1000 population in hospital settings is distributed as follows: 1.7 doctors, 2.93 nurses and 2.47 nurse associated professionals.
Spain was for a while a net supplier of doctors and nurses to countries such as the United Kingdom and Portugal. However, for most of the last decade, the shortage of health professionals has become the dominant issue in planning for health care personnel.
Principal health care reforms
The health reforms of the 1980s were mainly oriented to the extension of coverage and access to health care services, completing the transition from a limited social security system to a universal national health service funded from taxes. The economic context of the 1990s drove reforms in this period along the road of cost-containment and management innovation. The latest reforms implemented in the 2000s have followed the motto “coordination and cohesion after devolution”. The completion of total devolution of health competences to the ACs motivated a quest for mechanisms to balance the tension between federalization (regionally driven policy) and a national coherent view guaranteeing Spaniards’ equal rights regardless of their region of residence. The reforms can be clustered as aimed to enhance four key elements in a devolved system.
1. Governing bodies and tools fitting the new federal architecture.Building on the foundational Health Care General Act, the 2003 SNS Cohesion and Quality Act framed the road map. The CISNS was upgraded to the highest SNS authority, paving the way to a brand new consensus-based policy- making process grounded in knowledge management. This approach
has been reinforced by the enactment of the SNS Quality Plan in 2005;
it has become one of the main drivers for the design, implementation and monitoring of quality standards across SNS, developing national health strategies to tackle both most prevalent chronic diseases (e.g. cancer, cardiovascular diseases, diabetes) and rare diseases, as well as the national strategy on patient safety.
2. Common benefits package. The new benefits basket dictated by the SNS Cohesion and Quality Act was to be comprehensive enough to include all the services listed in the 1995 basket and updated to include new benefits consolidated in the meantime. Enforced from 2006, it also dealt with modernizing some concepts, such as public health benefits; the other innovation consisted of the prescription of an agreed updating procedure explicitly regulating the mechanisms and requirements for benefits inclusion in the common basket. It stressed the role of health technology appraisal and a cost-effectiveness approach to assessment.
3. Allocation and distribution of funds to support regional administrations in assuming the devolved competences. The 2001 revision of the regional financing law was the first allocation scheme in which health care ear marked transfers were abolished and integrated in the general funds allocation system (together with the rest of devolved competences). However, the system has shown some flaws that the new revision
passed in 2009 is intended to address as from 2011 general budgets. The modifications increase ACs’ fiscal autonomy compared to the
previous model, raising the share of partly ceded major taxes to
50% (personal income, VAT) and of manufacture taxes up to 58% (hydrocarbons, alcohol, tobacco). It also refines the tools for enhancement of horizontal and vertical equity: the allocation makes available levering block-grants to guarantee that those ACs in the lower range of income can provide the same amount and quality of services as those in the higher income brackets. In addition, the per capita criterion is modified, shifting to population adjusted by effective health protected population, population of school age and aged 65 and over, plus the previous geographical factors.
4. National information system, able to account for both regional and national levels, allowing for transparency in monitoring performance and resources distribution across the country. The SNS Quality Plan includes the work in progress to implement the national health information
system, a single patient ID containing relevant clinical information or the development of a single eCR to be used across the country, thus creating the basis for the SNS functional single insurer and guaranteeing to patients continuity of care outside their AC of residence.
Assessment of the health system
Measured by international standards, the SNS ranks, in general, in a fairly good position yielding sustained good results in different dimensions of performance such as:
• population health status parameters
• coverage, access and financial equity parameters
Health systems in transition Spain xxix
• health care amenable outcomes, health care quality and safety
• users’ satisfaction and system legitimacy according to the population
(except for patient-oriented information and waiting list management).
These achievements have been attained with a relatively low level of expenditure (currently 8.5% of GDP in Spain, which is below the European average). The conclusion would then be that overall Spaniards are obtaining quite good value for money.
Although international comparison offers important insights, in the case of a quasi-federal country like Spain assessment across the country becomes crucial. In fact, from the perspective of geographical differences in utilization and outcomes there is evidence suggesting large unwarranted variability in access, quality, safety and efficiency, not only across regions but mainly among health care areas and hospitals. For example:
• Variations in utilization of percutaneous transluminal coronary angioplasty (PTCA) are as large as five times between health care areas; although PTCA use has increased over time, these differences remain. Likewise, variation in mortality risk following a PTCA can be two fold, depending on the hospital.
• Variability in inappropriate use of procedures has been also analysed; prostatectomy rates (with all the controversy about its impact on cancer survival) are increasing over time and so is variability across health care areas (by as much as 7.7 times); Caesarean sections, on the other hand, are increasing unwarrantedly, while variability among hospitals is declining due to the convergence of all providers towards high rates.
• Safety indicators such as death rate caused by low-mortality diagnosis- related groups (DRGs), decubitus ulcer, catheter-related infection, pulmonary thromboembolism and deep-venous thrombosis after surgery or post-operative sepsis registered differences in rates across health care areas ranging from 2.2 to 4.5 times more frequent in one area than another.
• Regarding the management of chronic conditions, avoidable hospitalizations related to short-term diabetes complications can be as much as 12 times more frequent, depending on the health care area, and this variability has only increased over the years; similarly, admissions to acute care hospitals due to affective psychosis can be 28 times more frequent in one area than another.
Health systems in transition Spain
• Differences in technical efficiency index across hospitals (clustered by size), are notable: 26% of hospitals, with more than 501 and less than 1000 beds, were at least 15% more inefficient than the standard. At the same time,
12% of hospitals with more than 201 beds and less than 500 were, at least, 25% less efficient than the standard for treating similar patients.
Beside this quantitative evidence, there have been several initiatives to collect SNS stakeholders’ opinions on the main challenges faced by the SNS. Different stakeholders (patients, professionals and policy-makers) seem to agree on referring to information as the basis for improving the SNS quality, reliability and sustainability.
Although major steps have been taken in developing the technological basis, the health care system information in Spain lacks a common performance measurement framework. In fact, the system is still too based on resources or activity data (to the detriment of outcomes information), and connectivity between health care information systems (within and between regions across the country) is still limited. This situation has hampered the possibility of systematic assessment of SNS performance, whatever the level of disaggregation.
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