Health System Decentralization in Spain

Dr. Antonio Durán

London School of Economics14 September 2010

London School of Economics14 September 2010

Main topics to be addressed

- Division of competencies, - Political reasons behind devolution, - How it works in practice; - Results

Spain, some data 2010

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

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.)

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.

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

Infant deaths/ 1000 live births

20.78 12.41 7.6 4.38 3.78 3.35

Summary health indicators 1970-2008 (selected years)

Source: European Health for All Database, May, 2010 (*) Instituto Nacional de Esadística, May 2010Source: 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%

Mortality in medical care sensitive conditions1

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%

Years of life potentially lost (1–70)2

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%

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]

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 ratesSelected cancers. Five-year relative survival ratesEUROCARE–42 EUROCARE–42 EUROCARE–43

1990–1994 1995–1999 2000–2002

Breast (women) 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%

Colorectal 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%

Lung 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. 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): 1–290García 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”

Agencia de Calidad del SNS. Instituto de Información Sanitaria, 2010, Barómetro Sanitario 2009.

61,3

67,468,1

69,2

56

58

60

62

64

66

68

70

1995 …. 2007 2008 2009

Years

% o

f re

spon

den

ts

Health expenditure as % of GDP, selected European countries 2008

Joint OCDE, WHO and EUROSTAT National Health Accounts, www.who.int/country/en, June 2010

3,7

4,7

5,2

6,5

6,6

6,8

6,8

7,2

7,3

8,4

8,6

8,7

8,7

9

9

9,1

9,1

9,7

9,7

9,9

10,1

10,1

10,4

10,5

11,1

0 2 4 6 8 10 12

Kazakhstan

Romania

Russian Federation

Belarus

Poland

Czech Republic

Ukraine

Luxembourg

Bulgaria

Finland

Norway

Spain

Ireland

Italy

United Kingdom

Netherlands

Sweden

Belgium

Greece

Denmark

Austria

Portugal

Germany

Switzerland

France

OECD, Per Capita Health Spending US$, 1960-2007

*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)

1960 1965 1970 1975 1980 1985 1990

Australia 99 127 219 463 696 998 1,310Austria 69 94 172 389 716 984 1,383Belgium 55 84 135 320 607 879 1,242Canada 109 155 264 457 773 1,244 1,811Denmark 70 125 226 363 618 807 1,051Finland 57 95 172 320 539 855 1,291France 75 124 215 409 736 1,083 1,528Germany 98 135 228 484 856 1,175 1,522Greece 16 27 61 107 192 282 400Iceland 53 88 146 307 611 889 1,379Ireland 37 52 102 246 477 572 748Italy 51 83 162 296 600 814 1,296Japan 27 64 133 269 540 792 1,119Luxembourg - - 160 340 657 930 1,392Netherlands 74 106 222 441 742 931 1,286New Zealand 49 77 183 369 568 747 995Norway 95 - 141 322 573 846 1,193Portugal - - 48 166 265 398 554Spain 14 38 87 198 342 452 774Sweden 94 151 285 496 897 1,150 1,455Switzerland 96 141 281 541 886 1,224 1,640Turkey - - - 39 67 66 133UnitedKingdom

80 101 155 286 474 685 985

United States 143 204 346 592 1,064 1,711 2,601

OECD average 70 104 180 343 604 855 1,212

2000

1,730 2,277 1,918 1,783 2,574

1,855 2,373 2,580 2,041 1,416 2,283

845 1,071 2,456 3,564

118 1303

4,187

1,789 2,369

1326

2,713 905

2,149

1,984

2007

3357 3763 3595 3895 3512

2686 2696 5686 3837 2454 4763 2283267133234417 6512992

7290

2840 3601

3424

3588 27273319

3049,5*

2008; sources of funds & expenses

% of public funds spent% of revenue by source

Source: García S, Abadía B, Durán A and Bernal E (2010) Spain: Health system review. Health Systems in Transition, 12 (4): 1–290

Private insurance 5.5%

Out-of-pocket 22.5%

Taxation 94,07%

Professional mutuality schemes 2.53%

Civil servants mutual funds 3,4%

PHC 16%

Pharmaceuticals 19.8%

Prevention & Public Health

1.4%

Other 8.8%

Specialist care 54%

Public sector funding 71 %

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 serviceEquity in accessIntegrationDecentralization

2003 SNS Cohesion and Quality Act shapes up the current decentralized health system

“Federal-like” system… without Federation

17 Autonomous Communities2 Autonomous Cities

Parliaments elected by direct vote Regional Governments

National Government +2-Chamber Parliament

Regional Ministries of Health coordinated by the Ministry of Health and Social Policy

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).(C

oh

esio

n a

nd

Qu

alit

y L

aw. 2

003)

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

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

79,5

79,8

80,4

80,4

80,5

80,6

80,6

81

81,1

81,1

81,5

81,6

81,6

81,6

81,7

81,8

82,1

82,5

82,5

75 76 77 78 79 80 81 82 83

Ceuta/Melilla

Andalucía

Asturias

Canarias

Murcia

Com. Valenciana

Extremadura

Galicia

Cantabria

Average SPAIN

Castilla-Mancha

Baleares

Cataluña

País Vasco

Aragón

La Rioja

Castilla y León

Madrid

Navarra

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)Montero-Granados, R et al, 2007, Social Science & Medicine 64, 1253–1264, Decentralization and convergence in health among the provinces of Spain (1980–2001)

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

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

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

Public health care expenses per person, 2010 (budgeted)Public health care expenses per person, 2010 (budgeted)

“Progressive”

“Conservative”

“Nationalist”

Public healthcare budget per capita > average national public healthcare budget of1343 Euros Public healthcare budget per capita < average national public healthcare budget of1343 Euros

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

Public healthcare budget per capita and political sign of the Regional Government 2010

2007 public per capita health expenditure by region

Source: FADSP, Ministry of Health as per EL País, 3 January 2008

1,224.19

11.61

GALICIA

1,235.03

4.98

ASTURIAS

1,471.59

24.45

CANTABRIA

1,342.27

19.40

PAÍS VASCO

1,339.48

15.11

NAVARRA

1,160.11

3.66

C. Y LEÓN

1,093.69

9.16

MADRID

1,349.44

11.92

EXTREMADURA

1,212.02

16.70

CANARIAS

1,282.22

14.31

ARAGÓN

1,087.51

4.24

BALEARES

1,058.68

14.07

C. VALENCIANA

1,170.39

11.10

TOTAL

1,176.37

14.82

MURCIA

1,089.25

11.34

ANDALUCÍA

1,249.31

15.60

C. LA MANCHA

1,224.19

11.61

LA RIOJA

EXPEND. 2007

VARIATION 06-07(%)

Sustainability concerns… (> 130% growth in capital expenditure in 2000–2008!)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

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): 1–290García 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”.

“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

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).

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): 1–290García S, Abadía B, Durán A and Bernal E, 2010, Spain: Health system review. Health Systems in Transition, 12 (4): 1–290

Agencia de Calidad del SNS. Instituto de Información Sanitaria, 2010, Barómetro Sanitario 2009.

Respondents who believe that same health services are offered to all citizens despite…Respondents who believe that same health services are offered to all citizens despite…

45,3

87,5

68,8

43,3

88,6

70,6

42,0

87,1

70,1

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

90,0

100,0

Autonomous Community of residence

Patient's gender Patient's social class and wealth

Perc

en

tag

e

2007

2008

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

Nurses 316.2 406.8 576.9 642.2 741.5 n/a

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 over-centralised 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