Is Spanish public health sinking?BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7445 (Published 23 November 2011) Cite this as: BMJ 2011;343:d7445
Despite the perception of it being chronically sick, the Spanish health service has a few things to shout about: it has a broad portfolio of services, achieves universal coverage (including for illegal immigrants), and provision is free of charge at the point of delivery (with the exception of drugs prescribed to people aged under 65, which entail a 40% copayment).1 The Spanish system was listed in 2000 as the seventh best healthcare system in the world by the World Health Organization2 and the third according to Newsweek in 2010.3
Spain has low infant mortality—3.3 per 1000 live births—and one of the highest life expectancies in the world—81.8 years.4 Moreover, Spain is an international benchmark in areas such as organ donation and transplantation.5 Though deceased organ donations are dropping in most countries that have been hit hard by the financial crisis—down 56% since 2008 in Greece—Spanish numbers remain on the rise.6
All that with only €70bn (£60.1bn; $94.9bn);7 about €1500 per person, 73.6% of total health expenditure, 6.5% of GDP.4 A low cost health service. This is not due to especially good management but to low wages; staff account for only 50% of the total health budget, the lowest proportion in western Europe. The Spanish National Service is the country’s biggest employer, generating 0.6 million direct jobs and up to 1.5 million indirect jobs.
It sounds unsinkable, but is the Spanish health service a new Titanic?
Spain is divided into 17 autonomous communities, and 13 held regional elections this May. This electioneering saw an increase in scaremongering about the health service in the mostly conservative media. After the conservative People’s Party—the national opposition until the weekend—won a crushing victory, the number of media reports about the health system’s unsustainability rose strikingly Budget cuts have been particularly pronounced in Catalonia,8 which is governed by Catalan nationalist party Convergence and Union (CiU).
There is no doubt that the financial crisis is affecting the health service.9 But historical inefficiencies are also a real problem. For example, the health service owes an alleged €15bn to suppliers, including €5.5bn for drugs, €4.7bn for health technology, and €0.4bn to pharmacies, and payment delays are more than 400 days on average.
“The argument of the debt crisis is being used to introduce important changes in the health service, mainly the introduction of private management of public services,” says Javier Rey del Castillo, who is responsible for health at the think tank Fundación Alternativas. Indeed, privatisation has grown almost exponentially over the past decade, mainly in regions administered by the People’s Party.10 For its part, CiU has a project to increase private capital input in Catalonia,11 which has extensive links to the private sector for historical reasons.
In a new report, Mr Rey calls for a new general health act because the current law allows “the unstoppable introduction and poorly controlled use in terms of efficiency of new health technologies, including drugs.”12
“There is not a rational use of technology,” says Margarita Alfonsel, general secretary of the Spanish Federation of Healthcare Technology Companies (FENIN), recalling meetings in which a region wanted to purchase certain technology because the one next door already had it.
“In the last six years the average number of prescriptions per person has grown by 20%,” says Jaume Puig, professor at the Center for Research in Health and Economicsat Pompeu Fabra University in Barcelona. “We have put under the umbrella of public coverage almost any innovation or marketed drug, regardless of whether the cost per quality adjusted life year was reasonable or totally exorbitant.”
Spain is one of the highest consumers of drugs in Europe. Although it has succeeded in reducing outpatient drug costs (from €12.5bn in 2009 to €12.2bn in 2010) through various measures,13 14 experts agree that the decreases will not last if structural changes are not implemented. Hospital drug expenditure is out of control and has grown by 55%, from about €3.7bn in 2006 to almost €5.8bn in 2010.15
Expectations and transparency
The widespread cuts and new forms of copayment being introduced in Catalonia8 16 seem to mark a way forward. There is a widespread perception in Spain that these types of cuts will now be widespread despite the fact that no party openly spoken about them during the general election. Santiago Cervera, a member of the newly elected People’s Party and former head of health department of Navarre, says only that “we must be clear what the priority is.”
A bit of history
Although Spain is not a federal state, it behaves as though it is. Between 1981 and 2002 healthcare was decentralised to the regions, resulting in wide variations in spending and outcomes.17 Around 30-40% of regional budgets are allocated to health. Regions collect about 50% of their money directly through taxes and central government allocates the other half. Although it is no longer common for patients to have to change ambulances at regional borders, the ongoing rivalry between administrations explains part of current situation.
A decade of excess
Between the regional elections in 2003 and 2007, enormous sums were spent on infrastructure and improving wages, explains José Ramón Repullo, professor at the National School of Health. The proportion of GDP devoted to health increased from 5.4% in 2004 to current 6.5%, a “health bubble” according to Professor Puig.
Central government would often bail out autonomous regions, who habitually underbudgeted. In 2005, with the Spanish GDP growing by 3.4%, the prime minister, José Luis Rodríguez Zapatero, paid out €1.7bn.
The collapse of Lehman Brothers in 2008 marked a turning point in the attitude towards debt. Local policy also gained more weight, which favoured the development of “proximity hospitals,” says Professor Repullo. This policy of localisation has influenced a strong tendency to specialised and hospital medicine, which moves the system further away from cost efficiency according to Albert Jovell, president of the Spanish Patients’ Forum. The primary care system has been largely forgotten. “Rather than improving care, [development] has focused on the number of health centres built,” says Mr Rey.
In Madrid, for example, which has 6.5 million inhabitants, 10 hospitals have been built since 2003 (with two more under construction) as well as 74 health centres (with 13 more planned), even though the population has not increased enough to justify this expansion. Although “people are happy, but it is not easy for the facilities to be profitable,” says Professor Repullo.
But not all regions have the same level of debt. Castilla y León, Valencia, and Andalusia, account for 60% of the debt, whereas the Basque Country (1.3%), Navarra (0.2%), Extremadura (0.9%), and the Canaries (2%) have much lower amounts.
Almost all respondents agree that electioneering has prevailed. For Mr Cervera “a legal relationship between the budget and what you can spend should be established.” “Conditional funding to maintain some features of the system” will be necessary, says Mr Rey.
Growing lobby of the private sector
Private healthcare in Spain accounts for 26.4% of total health spending; 3% of GDP.4 Because public health coverage is currently universal and opting out is not possible (apart from civil servants’ mutual funds) people with private insurance are generally doubly insured. Around 8.8 million people (including 2 million civil servants), 18.8% of the population,18 have private cover, mainly to avoid waiting times (the most common complaint in the public system), to get direct access to a specialist, for certain elective surgeries, or to get a better services such as single rooms.
Voluntary private insurance (PVI), around 66% of total insurance,18 which dropped last year by 1.2%,19 is “ridiculously cheap” and has lots of “small print” says Professor Repullo. The widespread perception is that for a serious condition you have to use the public system, as confirmed by a recent survey by the General Council of Nursing.20
Recently, private health providers and insurance companies have redoubled efforts21 to access the system, mainly through the gradual boost in privatisation process,10 Mr Rey explains. According to José Martinez Olmos, former secretary general of the ministry of health, the repeated message of a health service in crisis “clearly” benefits the private sector.
As the existence of many private clinics depend on them, the private sector has lobbied hard to maintain the three mutual funds that cater exclusively to civil servants, a situation which Professor Repullo considers an “anachronism.” Though unfair, the new Public Health General Act22 has consolidated this model. “An atrocity,” says Mr Rey.
Data on health outcomes is hard to come by for both the private and public sector, making it difficult to make objective comparisons. Rafael Bengoa, regional head of health and consumer affairs in the Basque Country, thinks ideological debate should be abandoned and “results” shown.
Experts’ response is to walk not run
Though experts and professionals call for earmark funding and a national political agreement for health,23 24 political parties have never achieved it. As for cuts, many have wondered at the cutting of equally efficient and inefficient services, and at the lowering of wages to all professionals with no evaluation of productivity, as is happening in Catalonia. A recent report of the Association of Health Economics (AES)24 considers such cuts unfair and demand not further spending, but better.
The AES proposes a multiyear plan of debt refinancing, targeted funding, and disinvestment—an uncommon word in the Spanish political vocabulary—in interventions that are “of dubious value” (such as the prescription of statins for primary prevention of ischaemic heart disease or some elective surgeries) or unnecessary, such as much antibiotic prescribing. A so called “Hispa-NICE” independent evaluation agency is demanded, though “the only way to do this is with the participation of professionals,” notes Professor Repullo, a member of the AES.
Other proposals include modifying the “absurd” waiting list models that do not prioritise by seriousness or expected benefits; “redistribut[ing] the pharmaceutical copayment in a more balanced way”; giving back to professionals and health facilities according to results; strengthening the role of primary care; and improving transparency on results and conflicts of interest.
“I assume that the model cannot save, neither is it going to ruin, just change,” says Mayol. “We have to rationalise expectations, and that is a work of governance and political strategy—and for health professionals [because] sometimes we have launched messages of optimism based on our ego,” he says.
Spaniards do not know yet if the iceberg has been hit, but we have begun to hear the band, which, apparently, will not stop playing.
Cite this as: BMJ 2011;343:d7445
Competing interests: The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from him) and declares no support from any organisation for the submitted work; AGR works as a doctor in the public health system.
Provenance and peer review: Commissioned; not externally peer reviewed.