London School of Economics
14 September 2010
Health System Decentralization in Spain
Dr. Antonio Durán
Main topics to be addressed
-
Division of competencies,
Political reasons behind devolution,
How it works in practice;
Results
Spain, some data 2010
Total population
46,157,822
Foreign population
5.268.762 (non UE 60.1%)
Fertility rate
1.46 children per woman
Literacy rate
97.8%
GDP (2010 est.)
1,422.1 US$ billions
GDP per capita (2010 est.)
30,565 US $ at PPP
Recorded unemployment
19.8 (2010 est.)
National Institute of Statistics. http://www.ine.es Consulted May, 2010; The Economist
Intelligence Unit, March 2010, Spain Country Report p.17http://www.eiu.com
High in the world “health rankings”
- 4th in life expectancy at birth (3rd for females);
- 4th in life expectancy at age 65;
- 4th in female potential years of life lost;
- Under average in EU infant mortality (sixth in average
annual rate of decline since the 1970);
- Mortality for top causes since 1970 in Europe (CV
diseases, cancer and respiratory diseases) among the
lowest and in steady decrease.
Summary health indicators 1970-2008 (selected years)
1970
1980
1990
2000
2005 2008
Life expectancy at
birth, female
75.51
78.64
80.57
83.03
83.80
84.27
Life expectancy at
birth, male
70.14
72.46
73.42
75.95
77.09
78.17
Life expectancy at
birth in yrs
72.88
75.6
77
79.49
80.44
81.24
20.78
12.41
7.6
4.38
3.78
3.35
Infant deaths/
1000 live births
Source: European Health for All Database, May, 2010 (*) Instituto Nacional
de Esadística, May 2010
(*)
1991–2005 reductions in avoidable mortality
suggest substantive access, quality and safety
1991
1996
2001
2005
%change3
Mortality in primary prevention sensitive conditions1
Total
568.5
458.1
447.0
391.1
-31.2%
Male
861.9
697.2
686.7
609.7
-29.3%
Female
237.2
187.7
181.5
154.5
-34.9%
Total
138.6
108.3
88.7
79.6
-42.6%
Male
155.1
119.5
94.8
84.8
-45.3%
Female
120.1
95.5
82.0
74.0
-38.4%
Total
49.3
44.4
36.5
32.8
-33.5%
Male
64.7
63.6
51.7
46.2
-28.6%
Female
24.7
25.1
21.2
19.2
-22.3%
Mortality in medical care sensitive conditions1
Years of life potentially lost (1–70)2
INEBASE: Social Indicators 2006. INE, June 2008. [Primary prevention sensitive
conditions include: lung cancer, hepatic cirrhosis and motor-vehicle accidents.
Medical care sensitive conditions include: respiratory, circulatory and cancer. 1 per
10.000 deaths. 2 Adjusted rates per 1 000 inhabitants. 3 Relative reduction]
Selected cancers. Five-year relative survival rates
EUROCARE–42
Breast (women)
Colorectal
Lung
EUROCARE–42
EUROCARE–43
1990–1994
1995–1999
2000–2002
France
80.9%
82.7%
N/A
Germany
75.8%
78.3%
78.7%
Italy
79.7%
83.7%
83.7%
Spain
76.2%
80.8%
82.8%
UK (England)
72.4%
77.6%
77.8%
France
56.7%
57.5%
60.3%
Germany
52.4%
57.5%
61.4%
Italy
51.9%
57.4%
59.5%
Spain
50.5%
52.5%
61.5%
UK (England)
45.9%
50.8%
51.8%
France
14.0%
12.8%
N/A
Germany
11.7%
13.2%
14.1%
Italy
10.8%
12.8%
13.3%
Spain
11.4%
10.8%
12.2%
UK (England)
7.9%
8.6%
8.4%
Source: KantarHealth (2010) Oncology Market Access. Europe. Data taken from
the EUROCARE-4 study.
- Coverage: all citizens and residents -except
0.5%, high-income non-salaried individuals;
- PHC provided by publicly salaried professionals
(1 doctor & nurse for every 1,500 inhabitants
with numerous prevention programs);
- Public sector: 71.2% of available beds (40%
owned) with 80% of the acute beds pool, 36%
of psychiatric beds and 30% of long-term beds;
- High users’ satisfaction and system legitimacy
as per surveys (with specific exceptions).
García S, Abadía B, Durán A and Bernal E, 2010, Spain: Health system review.
Health Systems in Transition, 12 (4): 1–290
Respondents “SNS works quite well” +
“works well yet needs changes”
69,2
% of respondents
70
67,4
68
68,1
66
64
62
61,3
60
58
56
1995
….
2007
2008
Years
Agencia de Calidad del SNS. Instituto de Información Sanitaria, 2010, Barómetro
Sanitario 2009.
2009
Health expenditure as % of GDP, selected European countries 2008
France
Switzerland
Germany
Portugal
Austria
Denmark
Greece
Belgium
Sweden
Netherlands
United Kingdom
Italy
Ireland
Spain
Norway
Finland
Bulgaria
Luxembourg
Ukraine
Czech Republic
Poland
Belarus
Russian Federation
Romania
Kazakhstan
11,1
10,5
10,4
10,1
10,1
9,9
9,7
9,7
9,1
9,1
9
9
8,7
8,7
8,6
8,4
7,3
7,2
6,8
6,8
6,6
6,5
5,2
4,7
3,7
0
2
4
Joint OCDE, WHO and EUROSTAT National Health Accounts,
www.who.int/country/en, June 2010
6
8
10
12
OECD, Per Capita Health Spending US$, 1960-2007
1960
1965
1970
1975
1980
1985
1990
2000
2007
Australia
Austria
Belgium
Canada
Denmark
Finland
France
Germany
Greece
Iceland
Ireland
Italy
Japan
Luxembourg
Netherlands
New Zealand
Norway
Portugal
Spain
Sweden
Switzerland
Turkey
United
Kingdom
United States
99
69
55
109
70
57
75
98
16
53
37
51
27
74
49
95
14
94
96
80
127
94
84
155
125
95
124
135
27
88
52
83
64
106
77
38
151
141
101
219
172
135
264
226
172
215
228
61
146
102
162
133
160
222
183
141
48
87
285
281
155
463
389
320
457
363
320
409
484
107
307
246
296
269
340
441
369
322
166
198
496
541
39
286
696
716
607
773
618
539
736
856
192
611
477
600
540
657
742
568
573
265
342
897
886
67
474
998
984
879
1,244
807
855
1,083
1,175
282
889
572
814
792
930
931
747
846
398
452
1,150
1,224
66
685
1,310
1,383
1,242
1,811
1,051
1,291
1,528
1,522
400
1,379
748
1,296
1,119
1,392
1,286
995
1,193
554
774
1,455
1,640
133
985
1,730
2,277
1,918
1,783
2,574
1,789
2,369
2,713
905
2,149
1326
1,855
2,373
2,580
2,041
1,416
2,283
845
1,071
2,456
3,564
118
1303
3357
3763
3595
3895
3512
2840
3601
3588
2727
3319
3424
2686
2696
5686
3837
2454
4763
2283
2671
3323
4417
651
2992
143
204
346
592
1,064
1,711
2,601
4,187
7290
OECD average
70
104
180
343
604
855
1,212
1,984
3049,5*
*Average for 2007 includes the 6 last members (Czech Republic, Hungary, Korea, Mexico, Poland and Slovakia).
Source: Schieber G, Poullier JP, Greenwald L, “US Health Expenditure Performance: International Comparison
and Data Update” Health Care Financing Review 1992; “Health Spending, Delivery and Outcomes in OECD
Countries,” Health Affairs 1993, WHO World Health Report 2000, OECD Health Data: Statistics and Indicators for
30 countries, (http://www.irdes.fr/EcoSante/DownLoad/OECDHealthData_FrequentlyRequestedData.xls)
2008; sources of funds & expenses
% of revenue by source
% of public funds spent
Other 8.8%
Prevention &
Public Health
1.4%
Professional mutuality
schemes 2.53%
Out-of-pocket
22.5%
Civil servants mutual
funds 3,4%
Taxation
94,07%
Pharmaceuticals
19.8%
Private
insurance
5.5%
PHC
16%
Public sector funding 71 %
Source: García S, Abadía B, Durán A and Bernal E (2010) Spain: Health
system review. Health Systems in Transition, 12 (4): 1–290
Specialist
care 54%
Health: Legal framework
Article 43 of the 1978 Constitution: recognizes the right to health
protection
1986 National General Health Law shifted from the 1948 Compulsory
Insurance scheme to a National Health System based on:
Universal service
Equity in access
Integration
Decentralization
2003 SNS Cohesion and Quality Act shapes up the current
decentralized health system
“Federal-like” system… without Federation
National Government +
2-Chamber Parliament
17 Autonomous Communities
2 Autonomous Cities
Parliaments elected by direct vote
Regional Governments
Regional Ministries of Health coordinated by
the Ministry of Health and Social Policy
(Cohesion and Quality Law. 2003)
Regions spend 89.81% of public funds -mostly
not ear-marked budgets transfers from State;
central administration 3%;municipalities 1.25%
Regional governments: health authority plus
health service (30% of AACCs’ total budgets).
But problems with
(i) Geographical differences in health outcomes
and financing
(ii) Large unwarranted variability in access,
quality, safety and efficiency
Life expectancy at birth, both sexes, by Autonomous Community
Navarra
82,5
Madrid
82,5
82,1
Castilla y León
81,8
La Rioja
Aragón
81,7
País Vasco
81,6
Cataluña
81,6
Baleares
81,6
Castilla-Mancha
81,5
Average SPAIN
81,1
81,1
Cantabria
81
Galicia
Extremadura
80,6
Com. Valenciana
80,6
Murcia
80,5
Canarias
80,4
Asturias
80,4
Andalucía
79,8
Ceuta/Melilla
79,5
75
76
77
78
79
80
Ministerio de Sanidad y Politica Social (2009) Indicadores de salud 2009. Evolucion de los
indicadores y el estado de salud en España y su magnitud en el contexto de la Union Europea,
http://www.msc.es/estadEstudios/estadisticas/inforRecopilaciones/docs/Indicadores2009.pdf
81
82
83
Healthcare decentralization in Spain has
shown no positive effect on convergence in
health, as measured by LEB and IM (…)
Some provinces improved their situation
overtaking others but the final result is one of
greater dispersion than at the start.
Montero-Granados, R et al, 2007, Social Science & Medicine 64, 1253–1264,
Decentralization and convergence in health among the provinces of Spain (1980–2001)
Public health care expenses per person, 2010 (budgeted)
País Vasco
1623
Extremadura
1609
Navarra
1543
Asturias
1507
Rioja
1443
Aragón
1419
Castilla-León
1360
Cantabria
1347
Castilla la Mancha
1346
Murcia
1334
Galicia
1333
Cataluña
1298
Canarias
1295
Andalucía
1180
Comunidad Valenciana
1122
Madrid
1108
Baleares
1066
Range: 557 Euros or 40’73% around the average of 1343
Euros (Balearic Islands 79,37%, Vs Basque Country: 120,84%)
Federación de Asociaciones para la Defensa de la Sanidad Pública (FADSP), In
Diferencias notorias en el presupuesto per cápita entre CC.AA.
http://www.medicosypacientes.com/5 Enero 2010
Public healthcare budget per capita and political
sign of the Regional Government 2010
“Conservative”
“Progressive”
Public healthcare budget per capita >
average national public healthcare budget
of1343 Euros
Public healthcare budget per capita <
average national public healthcare
budget of1343 Euros
“Nationalist”
Federación de Asociaciones para la Defensa de la Sanidad Pública (FADSP), 2010. En Diferencias notorias en el
presupuesto per cápita entre CC.AA., según un estudio de la FADSP, Anónimo, 2010.
http://www.medicosypacientes.com/5 Enero 2009
2007 public per capita health expenditure by region
GALICIA
ASTURIAS
CANTABRIA
PAÍS VASCO
NAVARRA
1,224.19
1,235.03
1,471.59
1,342.27
1,339.48
11.61
4.98
24.45
19.40
15.11
C. Y LEÓN
ARAGÓN
1,160.11
1,282.22
3.66
14.31
MADRID
TOTAL
1,093.69
1,170.39
1,224.19
9.16
11.10
11.61
LA RIOJA
EXTREMADURA
BALEARES
1,349.44
1,087.51
11.92
4.24
CANARIAS
ANDALUCÍA
C. LA MANCHA
MURCIA
C. VALENCIANA
1,212.02
1,089.25
1,249.31
1,176.37
1,058.68
16.70
11.34
15.60
14.82
14.07
Source: FADSP, Ministry of Health as per
EL País, 3 January 2008
EXPEND. 2007
VARIATION 06-07(%)
Sustainability concerns…
(> 130%
growth in capital expenditure in 2000–2008!)
Trends in health care expenditure in Spain, 1980 - latest available year
1980
1985
1990
1995
2000
2005
2006
2007
2008(
*)
Total expenditure on health, per
capita $US PPP
363
496
872
1193
1536
2267
2466
2671
2791
Total expenditure on health, %
of GDP
5.3
5.4
6.5
7.4
7.2
8.3
8.4
8.5
8.7
Public expenditure on health %
total expenditure on health
79.9
81.1
78.7
72.2
71.6
70.6
71.2
71.8
72.8
Private insurance % total health
expenditure
3.2
3.7
3.7
3.4
3.9
5.9
6.0
5.9
n/a
Out-of-pocket payments %
total health expenditure
n/a
n/a
n/a
23.6
23.6
22.4
21.5
21.0
20.3
OECD Health Data (June 2009). http://www.ecosante.org (*)Data for 2008:
World Health Organisation (March 2010) National Health Accounts- Country
Information. Spain . http://www.who.int/nha/country/esp.pdf
Unwarranted variability in access, quality, safety and
efficiency, across regions, health care areas and hospitals.
5-time variations in use of percutaneous transluminal coronary angioplasty
PTCA between areas; 2-fold variation in mortality after PTCA (hospitals)
7.7-time variability in prostatectomy rates across health care areas
Caesarean sections increasing unwarrantedly; variability among hospitals
declining due to the convergence of all providers towards high rates.
2.2 to 4.5 times higher fatality rates by low-mortality DRGs, decubitus ulcer,
catheter-related infection, pulmonary thromboembolism and deep-venous
thrombosis after surgery or post-operative sepsis across health care areas.
28 times more frequent admissions to acute care hospitals due to affective
psychosis among areas
26% of hospitals with more than 501 and less than 1000 beds, at least 15%
more inefficient than the standard;
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
García S, Abadía B, Durán A and Bernal E, 2010, Spain: Health system review.
Health Systems in Transition, 12 (4): 1–290
“Inequalities in health and healthcare in
Spain appear to be driven by income
inequalities and inequalities in service
use but not by inequalities in financing
and health expenditure. Region states
politically responsible for the
organization of healthcare did not exhibit
significant differences in health and
healthcare inequalities and tend to
exhibit a better equity performance”.
Costa-Font J and Gil J, 2009. Exploring the pathways of inequality in health, health
care access and financing in decentralized Spain, Journal of European Social Policy,
Vol. 19(5): 446–458
1992-2009 per capita expenditure variation
coefficient among Regions (changes in population
protected volume fail to explain this variability).
García S, Abadía B, Durán A and Bernal E, 2010, Spain: Health system review.
Health Systems in Transition, 12 (4): 1–290
Respondents who believe that same health
services are offered to all citizens despite…
100,0
87,5 88,6 87,1
90,0
Percentage
80,0
68,8 70,6 70,1
70,0
60,0
50,0
2007
45,3 43,3
42,0
2008
40,0
2009
30,0
20,0
10,0
0,0
Autonomous Community
of residence
Patient's gender
Patient's social class
and wealth
Agencia de Calidad del SNS. Instituto de Información Sanitaria, 2010,
Barómetro Sanitario 2009.
Public sector staff uncertain numbers.
Health care personnel/100000, 1980– 2007, selected yrs
Staff, 100.000
1980
1990
1995
2000
2005 2007
Physicians
n/a
369.8
247.4
316.4
376.8 375.6
Physicians, some
specialties
n/a
30.9
33.4
39.7
46.3
n/a
Dentists
10.5
26.6
35.7
43.7
51.0
56.2
Pharmacists
62.1
59.0
63.5
81.2
94.7
n/a
316.2
406.8
576.9
642.2
741.5
n/a
Nurses
WHO/Europe, European HFA Database, Consulted May 2010 quoted inGarcía S,
Abadía B, Durán A and Bernal E, 2010, Spain: Health system review. Health
Systems in Transition, 12 (4): 1–290
Health Information System in Spain. In
spite of very serious financial investments…
Still too based on resources or activity
data (to the detriment of outcomes
information)
Very limited connectivity between
Regional health systems and across
the country.
No systematic assessment of SNS
performance, whatever the level of
disaggregation
While decision-making at national level
has been decentralised, processes at
regional level have been rather overcentralised and many of the old central
approaches have just been copied.
Devolution has arguably affected staff and
patients /citizens voice on how health
services are managed.
Belenes, R. (2003) “Un balance personal de 25 años de gestión sanitaria moderna en el Sistema
Nacional de Salud”, Gaceta Sanitaria 17 (2): 150-6; Flores Juberías, C. (2003) “Spain: delegation
and accountability in a newly established democracy”, in StrØm, K., Müller, W., Bergman, T. (eds)
Delegation and accountability in Parliamentary Democracies, Oxford University Press
National Healthcare Agreement involving
all Regions and all Political Parties (not
signed yet)
-
Human Resources Policy
Common Services
Budget Sustainability
Common Health Policies
Quality and Innovation
Prevention of Drug Addiction