HEALTH POLICY AND PUBLIC
HEALTH IN SPAIN AND FRANCE:
COMPARING EUROPEAN UNION
NATIONAL HEALTH SYSTEMS
Public Health, Comparative Health Policy
and Law in the European Union:
A Transatlantic Dialogue
F. SEVILLA
April 24-25, 2006
WELFARE STATE
•
“LIBERAL”
MEANS-TESTED ASSISTANCE
MODEST UNIVERSAL TRANSFERS
(USA, AUSTRALIA)
•
NATIONAL INSURANCE MODELS
– SOCIAL INSURANCE MODEL
RIGHTS ATTACHED TO WAGE-EARNERS
UNIVERSAL ACCESS PAID BY STATE
PRIVATE INSURANCE & OCCUPATIONAL FRINGE BENEFITS
HAVE A MARGINAL ROLE
STATE’S REDISTRIBUTIVE ROLE: SMALL
(GERMANY, AUSTRIA, FRANCE)
– UNIVERSAL MODEL
RIGHTS ATTACHED TO CITIZENSHIP
STATE’S REDISTRIBUTIVE EFFECTS: SUBSTANTIAL
(SWEDEN, NORWAY, DENMARK)
F.Sevilla Madison 06
HEALTH CARE SYSTEMS MODELS
NATIONAL HEALTH
SERVICE
NATIONAL HEALTH
INSURANCE
LIBERAL
WELFARE STATE
MODEL
UNIVERSAL
SOCIAL INSURANCE
LIBERAL
RIGHT TO SERVICES
YES
YES
NO
MEANS-TESTED
FINANCING
TAXES
WAGES
CONTRIBUTIONS
INSURANCE POLICIES
Direct
COVERAGE
UNIVERSAL
TENDENCY UNIVERSAL
% UNINSURED
% UNDERINSURED
BENEFITS
EQUAL
TENDENCY EQUAL
Insurance Policy
USER’S CHOICE
RESTRICTED
PROVIDER
YES
ALLOCATION
RESOURCES
ADMINISTRATIVE
CONTRACTS
MARKET
HEALTH CENTERS
OWNERSHIP
PUBLIC
PUBLIC/PRIVATE
PRIVATE
CONTROL SYSTEM
ADMINISTRATION
SOCIAL PARTNERS
?
F.Sevilla Madison 06
PUBLIC SOCIAL EXPENDITURE
%GDP
35,00
30,00
25,00
20,00
15,00
10,00
5,00
0,00
Canada
France
Germany
Mexico
Spain
United States
EU15 average
1990
18,61
26,61
22,80
3,84
19,55
13,37
23,27
1995
19,62
29,24
27,46
5,43
21,39
15,40
25,44
2001
17,81
28,45
27,39
5,10
19,57
14,73
23,86
Source: OECD Fact Book 2006
TOTAL TAX REVENUE
%GDP
50,0
45,0
40,0
35,0
30,0
25,0
20,0
15,0
10,0
5,0
0,0
Canada
France1
Germany
Mexico
Spain
United States
EU15 average
1990
35,9
42,2
35,7
17,3
32,1
27,3
39,3
1995
35,6
42,9
37,2
16,7
31,8
27,9
40,1
2000
35,6
44,4
37,2
18,5
34,8
29,9
41,7
2003
33,8
43,4
35,5
19,0
34,9
25,6
40,5
Source: OECD Fact Book 2006
CITIZENS
DEMAND
ƒ TAXES
ƒ WAGES CONTRIBUTION
ƒ INSURANCE POLICIES
ƒ OUT OF POCKET PAYMENTS
ƒ FINANCIAL ALLOCATIONS
ƒ EQUITY
ƒ EFFICIENCY
ƒ HEALTH GAIN
ƒ EMPOWERMENT
(Competitive / Cooperative)
ƒ BENEFITS GUARANTEE
Financing/Coverage
Results
Management
Organization
ƒ EXPENDITURES
ƒ PURCHASES
ƒ INVESTMENT
ƒ KNOWLEDGE&DEVELOPMENT
ƒ HUMAN RESOURCES POLICIES
ƒ PROFESSIONAL RULES
ƒ CONTRACTS: Control & Results
ƒ LONGITUDINAL CARE
ƒ QUALITY POLICIES
ƒ CHOICE
ƒ EFFICIENCY CENTERS
SUPPLY
HEALTH CARE SERVICES
F.Sevilla Madison 06
SPAIN
• Health Care System:
– Universal, in transition from a Social Security
Model
– Decentralized to the Regional Governments
• Financing: Taxes
– CentralG to guarantee Equity and Solidarity
– RegionalG to finance Health Care Expenditures
• Provision: Mostly public, owned and managed
• Territorial Organization:
– Health Areas: Hospital care
– Health Zones (less 25.000 inhabitants): Primary Care
F.Sevilla Madison 06
SPAIN (2)
• Access:
– Free except Ambulatory Pharmacy
– Choice of GP inside Health Area
– No Hospital Choice
• Health delivery system: Integrated
– Primary Health Care: Health Care Centers in a
Professional team, Gatekeeper role:
•
•
•
•
Health Promotion
Health Prevention
Curative care: GPs, Pediatrician, nurses
Follow-up patients
– Hospital Care:
• Inpatient care
• Ambulatory specialized care including Ambulatory surgery
• Emergency care
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SPAIN (3)
• Payment Professionals: Salary, status
similar to civil servants
• Problems:
– Coordination of care
• Primary-Hospital
• Health-social care
– Waiting times for elective surgery
– Comfort and administrative procedures
– Staff Satisfaction
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FRANCE
• Health Care System:
– Social Security Model
– UNIVERSAL COVERAGE
– Centralized:
• STATE: Regulation, Public Health and “National Expenditure
Ceiling”
• Health Insurance Funds: General (84%), Rural (7,2%), SelfEmployees (5%), Others (3,8%)
• Financing: Wage Contributions
• Provision:
– Liberal: Ambulatory care
– Hospitals: Public 25%, Private non profit 35%, for
profit 40%
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FRANCE (2)
• Territorial Organization
– GP’s and Ambulatory care Specialists: Freedom of
Installation
– Hospital Sector: Regional Strategic Health Plan &
Medical Map
• Access:
– Direct Payment with reimbursement afterwards
(voluntary coinsurance)
– Statutory copayments, exemption is granted (chronic
conditions,…)
– Choice of Practitioner
– Choice of Hospital
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FRANCE (3)
• Health Delivery System:
– Public Health Services
– Ambulatory care:
• Curative care
• Self-employed professionals: Physicians, Dentists,
nurses
• GP’s can play a role of gatekeepers
– Hospital Care
• Private: focus on surgical procedures
• Public: focus on emergency, rehabilitation, longterm and psychiatric care
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FRANCE (4)
• Payment Professionals
– Fee for service: Ambulatory care and Private
Hospitals
– Salary: Public hospitals
• Problems:
– High Health Expenditure
– No financial risk to Insurance Funds
– Coordination of care
– Shortage of Professionals
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HEALTH STATUS
HEALTH: STATUS
Life expectancy at birth
years
Women
Men
Fertility rate
Infant mortality
Children per woman
per 1 000 live births
15-49
Total
2003
Tobacco
consumption
% of population
smoking daily
Overweight or
obese
Obese population
population
% total pop. BMI>25
kg/m
2
% total pop. BMI>30 kg/m
2003
1993
2003
1993
2003
1993
2003
2003
1993
Canada
82,1
77,2 79,7 1,52
1,66
5,4
6,8
17,0
25,5
46,5
14,3
12,1
France
82,9
75,8 79,4 1,89
1,65
3,9
6,5
28,6
29,0
37,5
9,4
6,6
Germany
81,3
77,4
75,5 78,4 1,34
72,4 74,9 2,40
1,28 4,2
3,04 20,1
5,8
29,6
24,3
26,4
22,9
25,1
49,2
62,3
12,9
24,2
..
..
83,7
80,7
79,9
77,2 80,5 1,29
76,2 78,5 1,71
74,5 77,2 2,04
1,27
1,75
2,05
6,7
6,3
8,4
28,1
26,0
17,5
32,1
27,0
20,4
48,4
62,0
65,7
13,1
23,0
30,6
8,8
15,0
23,3
Mexico
Spain
United Kingdom1
United States1
Source: OECD Health Data 2005
4,1
5,3
7,0
2
LIFE EXPECTANCY AT BIRTH, TOTAL POPULATION
2003
1960
67,8
81,8
Japan
Iceland
Spain
Switzerland1
Australia
Sweden
Italy
Canada1
Norway
France
New Zealand1
Netherlands
Austria
United Kingdom
Finland
Germany
Luxembourg1
Greece
Belgium1
OECD
Ireland1
Portugal
United States1
Denmark
Korea1
Czech Republic
Mexico
Poland
Slovak Republic1
Hungary
Turkey
72,9
80,7
69,8
80,5
71,6
80,4
70,9
80,3
73,1
80,2
69,8
79,9
71,3
79,7
73,6
79,5
70,3
79,4
71,3
78,7
73,5
78,6
68,7
78,6
70,8
78,5
69,0
78,5
69,6
78,4
69,4
78,2
69,9
78,1
70,6
78,1
68,5
77,8
70,0
77,8
64,0
77,3
69,9
77,2
72,4
77,2
52,4
76,9
75,3
70,7
57,5
74,9
74,7
67,8
73,9 70,6
72,4 68,0
48,3
68,7
90
Source: OECD Health Data 2005
80
70
60
Years
50
40
INFANT AND NEONATAL MORTALITY RATES, 2003
Iceland
2,4
Infant mortality
Japan
3,0
Neonatal mortality
3,1
Finland
3,1
Sweden
Norway
3,4
Czech Republic
3,9
3,9
France
4,1
Portugal
4,1
Spain
4,2
Germany
4,3
Belgium
4,3
Italy
4,3
Switzerland
4,4
Denmark
4,5
Austria
4,8
Australia
4,8
Greece
4,8
Netherlands
4,9
Luxembourg
5,1
Ireland
5,3
United Kingdom
5,4
Canada1
5,6
New Zealand2
6,1
OECD
6,2
Korea3
6,9
United States
7,0
Poland
7,3
Hungary
7,9
Slovak Republic
20,1
Mexico
29,0
40
Source: OECD Health Data 2005
30
1. 2002. 2. 2001. 3. 1999
Turkey
20
10
0
Deaths per 1 000 live births
HEALTH SPENDING
HEALTH: SPENDING AND RESOURCES
Health spending and financing
Public expenditure
Pharmaceutical
Total
as % of total
Average
Health expenditure expenditure as % of
expenditure as
expenditure on growth rate Per capita USD PPP total expenditure on
% of GDP
health
health
2003 1993 2003 1993 1998-2003 2003
1993
2003
1993
Acute care beds
per 1 000
population
Practising
physicians
Per 1 000
population
MRI scanner units
Per million
population
2003 1993 2003 1993 2003 1993
Canada
9,9
9,9 69,9 72,7
4,2
3 003 2 014 16,9
13
3,2
3,6
2,1
2,2
4,5
1,0
France
10,1 9,4 76,3 76,5
3,5
2 903 1 878 20,9
17,5
3,8
4,9
3,4
3,2
2,8
1,4
Germany
Mexico
11,1 9,9 78,2 80,2
6,2 5,8 46,4 43,2
1,8
4
2 996 1 988 14,6
583 397 21,4
13,2
..
6,6
1,0
7,7
..
3,4
1,5
2,9
1,4
6,0
0,2
1,4
..
Spain
7,7
7,5 71,2 76,6
2,6
1 835 1 089 21,8
19,2
3,1
3,5
3,2
2,5
7,3
2,1
United Kingdom
7,7 6,9 83,4 85,1
15 13,2 44,4 43,1
5,7
4,6
2 231 1 232 15,8
5 635 3 357 12,9
14,8
8,6
3,7
2,8
3,9
3,5
2,2
2,3
1,7
1,9
5,2
8,6
..
5,9
United States2
Source: OECD Health Data 2005
HEALTH EXPENDITURE AS SHARE OF
GDP, 2003
15,0
United States
Switzerland
Germany
Iceland
Norway
France
Canada
Greece
Netherlands
Belgium (1)
Portugal
Sweden
Australia (2)
Denmark
OECD
Hungary
Italy
New Zealand
Japan (2)
Spain
United Kingdom (2
Austria
Czech Republic
Finland
Ireland
Turkey
Luxembourg
Poland
Mexico
Slovak Republic
Korea
11,5
11,1
10,5
10,3
10,1
9,9
9,9
9,8
Private 9,6
9,6
9,4
Public
9,3
9,0
8,8
8,4
8,4
8,1
7,9
7,7
7,7
7,5
7,5
7,4
7,4
7,4
6,9
6,5
6,2
5,9
5,6
15
10
5
0
% of GDP
1. Public/private data refers to current health expenditure. 2. 2002.
Source: OECD Health Data 2005
HEALTH EXPENDITURE AND
GDP PER CAPITA, 2003
Health expenditure per capita
6 000
USA
5 000
4 000
CHE
NOR
LUX
ISL
DEU
CA N
NLD
FRA
B EL
DNK
A US SWE
A UT IRL
GB R
JPITA
N
GRC FIN
ESP
P RT
NZL
3 000
2 000
CZE
KOR
SVK
P OL
M EX
TUR
HUN
1000
0
0
20 000
40 000
GDP per capita (USD P P P )
Source: OECD Health Data 2005
60 000
Source: OECD Health Data 2005
9,6
9,5
Austria
Czech
7,5
7,4
7,4
Mexico
Slovak
Poland
Korea
9,0
9,7
Finland
Turkey
9,8
Italy
Spain
10,2
10,0
Japan (2)
11,0
Ireland
10,3
11,1
OECD
Hungary
11,2
11,3
Greece
11,2
11,4
Portugal
Australia (1)
11,6
Sweden
Luxembourg
11,9
12,3
France
11,8
12,4
Canada
Belgium
12,5
Netherlands
Denmark
12,6
13,8
0
Germany
4
13,9
7,8
8
Norway
12
Iceland
17,0
15,5
16
Switzerland
United States
CURRENT HEALTH EXPENDITURE, 2003
Share of final consumption
20
SHARE OF POPULATION AGED 65 AND OVER
20
19
18
18
17
16
16
16
14
13
12
12
12
12
10
10
9
9
8
8
6
5
4
2
0
ITALY
GERMANY
SPAIN
FRANCE
UNITED KINGDOM
1960
Source: OECD Health Data 2005
2003
CANADA
UNITED STATES
MEXICO
Ja
p
K an
o
M rea
ex
Tu ico
G rke
r y
S Hueec
lo n e
N vak ga
et R ry
he e
r p
P land .
or s
t
P uga
ol l
S an
w d
ed
en
O
E
C U
D
A aK
us vg
t
Fi rali
nl a
Ire and
C Ca lan
ze n d
ch ad
D Ra
en ep
m .
Fr ar
G an k
er c
m e
an
S
w
itz It y
er aly
la
S nd
pa
i
U n
A SA
N B ust
ew e ria
l
Zegiu
al m
an
d
0
0,0
0,0
0,0
0,0
Source: OECD Health Data 2005
0,1
0,1
0,2
0,2
0,2
0,1
0,3
0,3
0,4
0,4
0,4
0,4
0,4
0,3
0,6
0,5
0,5
0,5
0,5
0,5
0,5
0,5
0,7
0,8
0,8
0,7
1,2
1,2
1,1
Heart transplants 2003
Number of transplants per 100 000 population
1,4
1
Ja
Tupan
Ic rke
e y
M lan
Lu ex d
x K ic
S emor o
lo b ea
va o
k urg
R
G ep
A ree .
us c
tra e
lia
N
I
ew P ta
Zeola ly
al nd
an
d
G
er U
mK
O Fi an
E nl y
C a
D D and
en v
g
H ma
un rk
g
Ire ar
P la y
or n
C tug d
a a
S nad l
w a
e
Fr de
N B an n
et el ce
C hergiu
z la m
S ech nd
w R s
itz e
er p
.
N lan
or d
A wa
us y
t
S ria
pa
i
U n
SA
1
1,0
0,9
0,7
2
2,1
1,9
1,8
1,8
1,6
3
Source: OECD Health Data 2005
4
4,0
3,9
3,7
3,7
3,6
3,5
3,5
3,4
3,4
3,3
3,3
3,1
3,1
3,0
2,9
2,8
2,7
2,7
2,7
5
0
5,2
5,1
4,7
4,6
Kidney transplants 2003
Number of transplants per 100 000 population
6
Source: OECD Health Data 2005
3
1
4
9
13
11
16
21
21
20
19
18
19
17
24
30
29
29
29
34
33
2003
43
40
40
39
39
37
40
9
8
9
8
9
18
20
1990
U
SA
0
0
6
13
24
30
5
4
4
10
1980
S
pa
in
A
us
tri
a
D
en
m
N
ar
ew
k
Ze
al
an
d
A
us
tra
lia
Fr
an
ce
O
E
C
D
av
g
P
or
tu
ga
l
Fi
nl
an
d
C
an
ad
a
2
10
U
K
G
er
m
an
y
Ic
el
an
d
Functioning kidney transplants,
1980, 1990 and 2003
Number of patients per 100 000 population
50
EUROPEAN SOCIAL MODEL
VALUES
• SOLIDARITY AND EQUITY
• REJECTIONS OF ALL FORMS OF
DISCRIMINATION
• GENDER EQUALITY
• UNIVERSAL ACCESS TO EDUCATION
AND HEALTH CARE OF GOOD QUALITY
• EMPLOYMENT, PROTECTION AGAINST
UNEMPLOYMENT
• PENSIONS
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EUROPEAN SOCIAL MODEL
CHARACTERISTICS
• EUROPE IS DEFINED BY ITS DIVERSITY
• THE EUROPEAN SOCIAL MODEL IS NOT MONOLITHIC
• THERE ARE DIFFERENT MODELS AND POLICY
CHOICES TO DEVELOP THE COMMON VALUES
• SUBSIDIARITY: POLICIES MUST BE DESIGNED AND
IMPLEMENTED AT THE LEVEL WHICH IS THE MOST
EFFECTIVE
• EMPLOYMENT AND SOCIAL POLICIES ARE
ESSENTIALLY OF THE DOMAIN AND COMPETENCES
OF MEMBER STATES
• SOCIAL POLICY IS SEEN AS A PRODUCTIVE FACTOR
IN THE MOST DYNAMIC COUNTRIES
F.Sevilla Madison 06
EU HEALTH CARE: LEGAL FRAMEWORK
• PRINCIPLE OF TERRITORIALITY AND
SUBSIDIARITY: The responsibility lies with the
Member States
• SOCIAL SECURITY COORDINATION: a
mechanism was set up in 1958 to ensure
workers mobility. No discrimination. Recognition
of Social Security benefits elsewhere in the
Union
• EU’s ROLE IS MAINLY SUPPORTING,
COORDINATING AND COMPLEMENTARY
• EUROPEAN COURT OF JUSTICE: to make
compatible the national systems and the free
movement. Only barrier to hospital access and
only in case of similar treatment at home
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WHO MIGHT SEEK HEALTH CARE ABROAD?
• TEMPORARY VISITORS: E-111 scheme -enables to
obtain care abroad in the event of an emergency- / health care
insurance card
– TOURISM: Young, Active Life
– BUSINESS TRAVEL
• LONG-TERM RESIDENTS ABROAD: Health care
entitlement is transferred to the new residence country
– TOURISM: Retired, social care
– WORK
• “EUROPEAN CONMUTERS”: There is not yet
mechanisms to link two health care entitlements
• PEOPLE USING FACILITIES LOCATED IN
BORDER REGIONS: Hospital of Puigcerda (SpanishFrench Border); double-access eligibility of frontier workers
• PEOPLE SENT ABROAD BY THEIR OWN
HEALTH FUNDER: E-112 scheme, Highly-specialized
facilities, pre-authorization required
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