Spain Health Profile 2012

The Spanish health system is made up of a conglomerate of public and (with less influence) private organizations, resulting in a totallydecentralized system.  Some departments and institutions have been
deliberately omitted to give a clearer picture of the organizational set-up. The situation is further explained in Chapter 2 on the organizational structure of the health system.

Health status

Health indicators in Spain have been improving constantly since the 1970s. The average life expectancy in Spain is one of the best in the world and was 83.15 years for females and 76.42 for males in 2003. Life expectancy for women was the highest in the EU in 2003.The main causes of death in Spain are diseases of the circulatory system, malignant neoplasms, diseases of the respiratory system and mental disorders. Mortality due to diseases of the circulatory system has been reduced twofold since 1970. Nevertheless, these diseases accounted for almost one third of all deaths in 2003. The second largest and increasing cause of death since the 1970s has been malignant neoplasms. Mortality from cancer of the trachea/bronchus/lung has doubled since 1970, which might be attributed to the smoking habits of the population. Mortality due to mental disorders and diseases of the nervous system has also been increasing since the 1970s, while mortality due to external causes shows a slight decrease during the same period.
 
One of the reasons for the improvement in life expectancy indicators is lower infant mortality rates. Infant mortality has been rapidly decreasing since the mid-1970s, at a rate very similar to average EU levels. In 1970, the rate was 20.78 per 1000 live births, while in 2003 it was 3.92. According to the United Nations Development Programme (UNDP) Human Development Report for 2004 (UNDP 2004), the indicator on infant mortality in Spain is second only to Sweden worldwide, along with Denmark, Finland, France, Germany and Norway. Traffic and occupational accidents are significant public health problems in Spain. During 2003, 5399 people died and more than 26 000 were seriously  injured due to traffic accidents. It was estimated that economic costs resulting from traffic accidents amount to approximately 2% of GDP (Ministry of Health and Consumer Affairs 2005). Interventions to tackle the issue of traffic accidents include epidemiological studies, media and education campaigns, and intersectoral collaboration. As for occupational injuries.

The development of Spanish social protection began during the last quarter of the 19th century, within the framework of the newly created Commission on Social Reforms. During the early 1900s, the National Institute of Social Insurance (Instituto Nacional de Previsión, INP) was created to coordinate the design and implementation of the first social insurance policies.The first attempt to develop social health insurance for low-salaried workers was launched by the INP during the era of the Second Republic (1931–1936). At that time, all political parties supported the introduction of a comprehensive social insurance scheme, although with different ideological and political motives. In 1936, the coup by General Franco started a civil war (1936–1939) that led to the establishment of an authoritarian regime, which lasted until 1975. After the civil war, many of the previous policy proposals were somehow recovered by the Francoist Government. Social security-related health care was run through the INP from 1942 by the Ministry of Labour and Social Security, until 1977.

The predominance of public provision within a social security system was the main feature of the Spanish health care sector. Until the approval of the Basic Social Security Act of 1967, the coverage of the population was rather limited. With the expansion to self-employed professionals and qualified civil  servants, it rose from 53.1% in 1966 to 81.7% in 1978. The vast majority of PHC provision was therefore public when the transition to democracy occurred, with general practitioners having the status of civil servants. In addition, an extensive publicly owned network of centres and services for general medical care, and specialized outpatient as well as inpatient care was developed during the 1960s. Such activity reached its highest point with the development of an extensive, modern public hospital network during the 1960s and 1970s by the Ministry of Labour and Social Affairs. From the mid-1960s, the public sector owned 70% of the available hospital beds, and employed 70–80% of the hospital doctors. These figures remained the same until the mid 1990s and public providers still
spent 75–85% of the public health care budget during the period 1975–1995.
Social security hospitals, in addition to providing health care to the bulk of the population, were also the driving force behind the training of specialists through a system of residency. In terms of budget during and after the Francoist period, specialized care was considered a priority over general medicine. It was provided either in small clinics (consultorios) made up of individual family doctors, or in ambulatory polyclinics (ambulatorios) along with a few outpatient specialties. At organizational level, primary care was highly fragmented, and divided among the largely uncoordinated state authorities. A ministerial ordinance, approved in 1972 (Ordenanza General sobre Régimen, Gobierno, y Servicio en las Instituciones Sanitarias de la Seguridad Social), regulated the management of health care provision in the period prior to the transition. Provincial delegations were the highest government authority at local level, headed by a provincial director appointed by the corresponding ministry. Within provinces, both ambulatory clinics and hospitals had a similar organizational structure (a medical director and a government council, mainly comprising social security civil servants, together with some representatives of health care personnel, the Francoist trade union, and the Organización Médica Colegial (Organization of Medical Colleges, OMC), the political body of the provincial colleges of physicians).
Responsibility for public health services was historically attributed to the central government and, in particular, to the Ministry of Gobernación, equivalent to the Ministry of the Interior, the origin of which goes back to 1855. The role of the government was to attend to health problems liable to affect the overall population, leaving personal health care to several health care networks. The public health infrastructure an facilities varied only slightly, with some “tidal waves” of decentralization followed by recentralization. In addition, the network of general hospitals devoted to charity health care and infectious diseases, owned by municipalities and provinces, progressively reduced as the social security centres were taking over the pivotal role in health care provision.
Mental health care in psychiatric hospitals, however, continued to be provided by local governments. Other health care networks included health care for the military (Ministry of Defence); university hospitals (Ministry of Education);and prison health services (Ministry of the Interior).

Organizational overview

To a large extent, the current configuration of the Spanish NHS was formed during the transition to democracy. According to this design, the central government has the responsibility to promote coordination and cooperation inthe health sector, as well as to ensure that the quality of all services is guaranteed equity exists in relation to access to health care throughout the national territory. The government also reserves for itself certain competencies regarding foreign health, international relations, pharmaceutical policies, research and high-level inspection. Public health and health care planning competencies were transferred to the autonomous communities between 1979 and 1981, as common law. All ACs were given constitutional responsibility over the
multiple public health care networks, which coexisted prior to the inception of the social health insurance system (pre-SHI networks). These included public health, the previously existing networks for monitoring and treatment of infectious diseases, the charity-based system, most health promotion and prevention activities, the previous network for rural primary care, psychiatric care and some community care programmes. The operation of such networks represented approximately 15% of total public health care expenditure. Each AC then created a Health Service to manage health services, under a regional government department or health authority. The remaining 85% of expenditure corresponds to health care centres and personnel formerly included within the SHI system (SHI network). Until 2001, the central government had only devolved responsibility for the health care network to seven regions (Andalucia, Basque Country, Canary Islands, Catalonia, Galicia, Navarra and Valencia), which together cover approximately two thirds of the Spanish population. A central institution, INSALUD, effectively managed most health care services in the other 10 regions. The transfer of the main social security health care network took considerable time and effort and was far from free of problems, mainly owing to disagreements between the central state and regional governments on financing issues. It was only completed as recently as 1 January 2002

The 1986 General Health Care Act defines the Spanish NHS, created from the social security health services and which during the 20th century constantly widened its coverage and services, as the ensemble of “all structures and public services at the service of health”, and “the combination of state administration and autonomous communities health services”.

The general principles of the National Health System are:

• universal coverage with free access to health care for almost allinhabitants;
• public financing, mainly through general taxation;
• integration of different health service networks under the National Health System structure;
• political devolution to the autonomous communities and region-basedorganization of health services into health areas and basic health zones;
• a new model of primary health care, emphasizing integration of promotion,prevention and rehabilitation activities at this level.

The act designed the Interterritorial Council of the National Health System as “a means of coordination”. Since its creation in April 1987 and until 2003, the CISNS was composed of a total of 34 members (17 representatives of the general state administration and 17 from the autonomous communities). From February 1997 the representatives of the autonomous cities of Ceuta and Melilla were also invited to assist, and from April 1999 the representative from Ceuta has full member status.
The Cohesion and Quality Act adopted in 2003 has changed the composition of the CISNS. Since then the CISNS has been composed of the Minister of Health and Consumer Affairs and the ministers responsible for health issues at regional level. Additional members of the central government or the regions can join CISNS discussions on specific topics by appointment of the central or regional ministers. Those guest members can take part in the discussions but have no vote. This current structure of CISNS reflects the current distribution of power in terms of health care responsibilities.

It is worth mentioning that there is no hierarchy between central government and the regional government in matters that have been transferred; since decisions of the CISNS must be adopted by consensus and they only affect matters that have been transferred to the ACs, they can only take the form of recommendations. In some cases, the ACs and central government can sign “covenants” or “agreements” that oblige both parties. This lack of real executive strength has been highlighted as a source of problems in terms of the efficiency of the Spanish health care system (Repullo, Ochoa et al. 2004; Elola 2004), as demonstrated by the difficulties encountered in guaranteeing equal access to deprived social groups, consolidating a stable system of financing, controlling the increase in health expenditure and coordinating and integrating the various services within the National Health System.

Since the 1980s, significant reforms have been implemented in the Spanish Health care system. This development resulted in constantly improving health indicators for Spanish citizens since the 1970s and high satisfaction levels with the health care system among users. In addition, achievements of these reforms include universal coverage, an extensive network of primary health care, high-quality hospital services, and reformed financing and management structures.
The General Health Care Act of 1986 stressed the importance of primary health care and has strengthened the role of the general practitioner as a gatekeeper to health care services. Primary health care is territory based and
there is very good access to health centres where mainly primary health care teams work. Extension of coverage to non-Spanish residents took place during the reforms of 1999–2000 and now 99.1% of the population are covered by public insurance, including low-income inhabitants, immigrant adults and immigrant children. A number of newly opened hospitals ensure good access to specialized care services. The legal basis for innovative forms of hospital and health centre management provided the stimulus for this change.

The Spanish health care system is a predominantly tax-based system. The %age of GDP for health care has been constantly increasing in Spain as in other industrialized countries, while public health expenditure plateaued for a number of years. Cost-containment initiatives were adopted, such as regional resource allocation, an explicit benefits package, and regulation of the pharmaceutical market (profit and commercial margins, reference prices, operating hours, etc.).
One of the most important characteristics of the Spanish health system is its decentralization reform, which was completed in 2002 after more than 20 years of development. Currently, the 17 autonomous communities have the authority to decide how to organize or provide health services. The Spanish Ministry of Health and Consumer Affairs establishes norms that define the minimum standards and requirements for health care provision. An important role in the stewardship of the Spanish health system is played by the Interterritorial Council of the NHS, which coordinates, sets up information systems and assures cooperation between national and regional health authorities.

In the context of the decentralized health care system an important event was the adoption of the Law on Cohesion and Quality of the NHS in 2003. This law outlines the framework of cooperation between public administration departments and proposes significant future reforms. A number of strategies, such as establishing the NHS Agency on Quality, the Health Information Institute and the National Observatory of the NHS, among others, have already been implemented.
Spain demonstrates success in effective public health interventions on lifestyle patterns, occupational health and accident prevention, among others. The Anti-tobacco Law came into force in 2006 and aims to tackle the high
prevalence of smoking through strict regulation of advertising and places to smoke; occupational health indicators show significant improvement after several adopted strategies in the field.

Despite the important achievements of the Spanish NHS since the 1970s, a number of challenges should be addressed in the near future. Similarly to other industrialized countries, cost-containment remains an important challenge for the Spanish NHS. Decentralization of the health care system resulted in a significant increase in health expenditure in most regions. Pharmaceuticals, inefficient purchasing and human resources expenditure increase, as indicated by interregional comparisons, are the main factors attributed to health expenditure increase. Concerted efforts at cost-containment at regional and central levelsare needed if the financial sustainability of the NHS is to be achieved. Emphasis should be put on the development of primary health care to achieve cost-containment and efficiency. Strategies for improving the professional status of general practitioners, modifying their workload, improving the access to GPs’services, ensuring the right to choose a GP and reducing the differences in terms of provision of PHC among the regions could be beneficial to this end.
There is an urgent need to improve users’ access to long-term and social care services and to address the increasing need for these services. The legal background to and provision of long-term care services varies across regions,but is limited in general terms. It is also important to strengthen research in health sciences. More efficient health policies should be implemented and the health system’s performance thereby improved.

A number of challenges also arise from the context of the decentralized health care system. The regional financing system is one of the most urgent health policy issues. The challenge is to achieve a consensus on important policy issues in the multilevel system composed of autonomous communities.
The government should therefore take into account a number of factors in order to decide upon the most appropriate method of health care funding for the regions.

The Spanish NHS lacks a well-developed information system, which is necessary for decentralized health care systems, for coordination and policy development purposes. Design and implementation of an information system for better cooperation between the central and local levels is among the future challenges.
Human resources issues in the Spanish NHS require special attention. So far, human resources have been oriented towards short-term values and have resulted in inadequate supply of health personnel. In the decentralized system, responsibility for human resources should probably stay at central level and through regulation ensure sustainable provision of the human workforce, achieve the adequate ratio of nurses and doctors and implement rational contracting policies.

Regional inequalities in health are additional challenges often faced by decentralized health systems. Regional health inequalities in Spain already existed before decentralization was complete, but they have been increasing
since. It is therefore important to ensure that the achievements of decentralization are not be outweighed by lack of equity.Coordination mechanisms are crucial in a decentralized context if objectives are to be achieved. It is therefore important to modify the roles, functions and responsibilities of the health care system and its actors.
The Spanish health care system performs rather well in many areas. The specific challenges identified in this report require concerted efforts at national and regional levels.