Spanish national healthcare system

KMUC HOSPITAL, Kaunas (Lituania)2007-05-29

BRIEF INTRODUCTION TO SPANISH

NATIONAL HEALTHCARE SYSTEM



Spanish population

• 44.108.000 total population (2005).

• 8,4% are foreing people.

• 16,7 % of total population are more than 65 years old.


Spanish population

Spanish Foreing citizens

Spanish population pyramide (2005)


Spanish Healthcare Regulation

• Spanish Constitution 1978, art. 43.• Main Principles fixed by Law

14/1986 (“General de Sanidad”).– Public funds, free of charge

attendance and none inhabitants to be excluded.

– Healtcare system descentralization to “Comunidades Autónomas”.


State’s role

• Main goals for central state government are to achieve:– Healthcare system’s general

coordination (”basic rules”). – Healthcare abroad and international

agreements.– Common rules for pharmaceutical

goods.


State’s role

• “Basic rules” are referred to:– Common rules reagrding equal reulations

within Spain for development of national healthcare system.

– Reporting information system to be shared between regional healthcare systems and central state’s government.

– Thecnical competence to be shared between regional healthcare systems.


State’s role

• Three levels for Public Healthcare Adminsitration– State: “Administración del Estado”.– Regional: “Comunidades Autónomas”.– Local: “Corporaciones Locales”.


State’s role

Central autorithiesBasic rules.Healtcare abroad.Phramaceutical goods.“INGESA”.

Regional autorithies(17)

Healthcare planning.Public Health.

Healthcare centres’ management

Local autorithies On going collaborative activities with regional & central autorithies

SHS’s Inter-

regional council


Transference process

• It begun in 1981 and finished in 2002, (Central State keeps direct management of autonomic cities Ceuta & Melilla).

AFRICA

EUROPE

Ceuta

Melilla


1981

198419871987

19901990

1994

Law

2001

Tiemtablefor transfer:

20 years



Transference process• Each “Comunidad Autónoma” has its

own “Servicio de Salud” (regional healthcare system).

• Coordination organization is called “Consejo Interterritorial del Sistema Nacional de Salud” (CISNS).

• Cohesion & Quality General Law (2003) is for:– Equity.– Quality.– Population’s participation.


From just 1 national healthcare system...


http://www.madrid.org/cs/Satellite?pagename=PortalSalud/Page/Satellite?pagename=PortalSalud%2FPage%2FPTSA_home&language=es


...to 17 regional heathcare services...

http://www.madrid.org/cs/Satellite?pagename=PortalSalud/Page/Satellite?pagename=PortalSalud%2FPage%2FPTSA_home&language=es


How to access to Heatlcare Services“Tarjeta Sanitaria Individual”


Financial resources

• Not insurance but tax-based system.– Healtcare is non/insurance cover service, it

is financed py taxes & impots. – Each “Comunidad Autónoma” manages its

own budget for its own regional healthcare system.

• There are two additional funds:– Cohesion fund, managed by Ministry of

Health Affairs.– Temporary Disability fund.


Financial resources

• 3 special insurance-based system for Public servants:– Civil servants (MUFACE). – Army (ISFAS). – Court and Tribunal servants

(MUGEJU).


Healthcare organization• 1st level “Atención Primaria”

– It is compulsory to go to 1st level before you can access to 2nd level.– 1st level is expected to be within a range of 15 minutes from your home, no

matter where you live.– “Centros de Salud” (Healtcare centers) are integrated by multiskilled teams

integrated by family doctors, pediatric specialists, nurses and administrative staff, plus social thecnicians, fisioteraphy specialists and obstetrician specialists. They are in charge of healtcare promoting and diseases’ perevention programmes and activities, even at your home whne needed.

• 2nd level “Atención Especializada”: – Major diagnosis and therapy media are assiged to 2nd level. – “Centros de Especialidades” (Specialties centers) y “Hospitales” (Hospitals) can

treat in-patients or ambulatory patientes too. Whne treated, patientes return t 1st level.

– “Áreas de Salud” (Healthcare Areas) are established by each “Comunidad Autónoma”.

– They are divide into several “Zonas Básicas de Salud” (Basic Healt Zones). – Each “Area de Salud” has its own Reference Hospital. Sometimes, “Areas de

Salud” may have some internmidiate orgizational structures which embrace a number of “Zonas Basicas de Salud”.


Healthcare OrganizationAn example of Area de Salud – Zona de Salud

La Rioja


Healthcare Organization

Area de Salud

Zona de Salud

An example of Area de Salud – Zona de Salud


1st healtcare level• Promotion, educational and prevention

programmes.• Clinical assistance , including both medical and

nursing activities, also at patiets” homes.• Rehabilitation and social support services.• Specific programmes:

– Women.– Childhood.– Adults & elderly people.– “Salud bucodental”.– Special Care for “terminal” patients.– Mental healthcare.


2nd healtcare level• In-patients at Hospitals.• Ambulatorial services.• “In-day” hospitals.• Others:

– Hemotherapy– Inefrtility.– Risk groups


Pharmaceutical cover-up• In-patientes:

– No co-payment system (totally free).

RETIRED PEOPLE

NON-RETIRED PEOPLE

“SINDROME TOXICO”

AIDS

CHRONICAL TREATMETS

0% 30%

40% 30%

10% (MAX. 2,69 EUROS

10% (MAX. 2,69 EUROS

0%

SOCIAL SECURITY COVERED BY

30%PUBLIC MUTUALITIES CIVERED BY


Other services

• Ortoprothesic material: special catallogue.

• Transportation: free when urgent or bcuase of disabilities.

• Dietethic products.• Information system.


Resources

454 en el ámbito de la sanidad privada, en los cuales el 40% de las altas hospitalarias corresponden a pacientes cuya asistencia ha sido concertada y financiada por el SNS.


Resources


Resources


Resources



Human Resources


Human Resources

27% of physicians in Secondary level are medical specialists, 23% work in central services and 18%

are surgical specialists.


Human Resources

82,2% physicians at Primary Level are family doctors and 17,8% are pediatric specialists.


Activity Indicators


Activity Indicators


Healthcare expenditure


Healthcare expenditure


Satisfaction of population

POPULATION’S OPINION (2004)


Satisfaction of population1999-2004 EVOLUTION


Life expectancy level• Spain’s Life expectancy at birth:

– 79,9 years.– (adjusted per disability: 72,6 years –

2002-).• EU’s Life expectancy at birth:

– 78,3 years.– (adjusted per disability: 70,8 years –

2002-). • .


Life expectancy levelMale-Female Life expectancy at birth (2002)


Transplantations

In 2004, transplantation rate (per million of inhabitants) was 34,6.


Mortality

• Car accidents:– 382 per each 100.000 pop.(2003).

• Accidentes at work:– 2.377 victimss per each 100.000 pop.

(one of the biggest in Europe).


Mortality

• 916 dead per each 100.000 inhabitants.

• Cardiovascular diseases and cancer are main causes of death (brest cancer for female and lung cancer and cardiovascular for male).

• 33,7% of total deaths are due to cardiovascular diseases and 25,9% due to cancer.


And finally...


• “At the beginning of 2002, the transference of authority over public health care services from the Spanish national health System (INSALUD) to all the autonomous communities hither to lacking this authority closed a period of modern healthcare management in Spain which, nevertheless, had lacked tHe dynamism and innovative capacity of business management. Despite this, during these 25 years, Spanish healthcare management underwent a spectacular growth”.

• “The problems of the Spanish public health system are either linked to:– the inherent problems of a system of universal coverage, with

generous provisions and clear underfinancing, – an obsolete organizational model in which centers and

healthcare professionals lack autonomy, – users' increased expectations the enormous complexity of the

medicine of the future”. • “Despite is serious defects and problems, the public values the

Spanish public health system; the main risk is chronic and progressive deslegitimation which causes users to lose faith and trust in the public health system”.

(1) “A new form of management appropriate to the new century”, R Belenes, Gaceta Sanitaria 2003 Mar. April 17(2):150-6 PMID: 12729543 [PubMed - indexed for MEDLINE].

A 1st final critical point of view(1)


A 2nd final critical point of view(2)

• “On June 24, 2000, the WHO released a report that assessed the world's health-care systems based on an overall index of performance ...”

• “In health-policy circles, the report caused some big surprises. At the top of the WHO's health-care league were countries such as Spain and Italy, whose health-care systems were rarely considered models of efficiency or effectiveness before. In Spain, for example, release of the WHO report, which ranked the Spanish system as the third best in Europe, after Italy and France, coincided with unprecedented demonstrations against the Spanish healthcare authorities”.

• “Something seemed profoundly wrong in the report's claiming that the performance of the Spanish system was the seventh best in the world An impressive 28% of the Spanish population (and an even more impressive 40% of the Italian population) indicated “there was so much wrong with their HCS (health-care system) that they needed to completely rebuild it”...

• “Who is right? ...”

(2) “Assessment of the World Health Report 2000”. Navarro V. The Lancet - Vol. 356, Issue 9241, 04 November 2000, Pages 1598-1601.


•“In the WHO's conceptualisation of medical-care effectiveness, the report uncritically reproduces a major assumption in medical-care cultures that medicine is very effective in reducing mortality and morbidity ,,, Actually, published literature shows that much of the widening gap in mortality rates within and among countries is primarily related to the growing differentials in wealth and income ...”

•“But it is wrong to explain a country's level of mortality by its medical services...The report erroneously attributes the low mortality in these countries to the effectiveness of their medical care. Actually, these various Mediterranean countries have different types of health services, but all share the characteristic that public expenditures in the health-care system as a percentage of gross national product are among the lowest in the EU ... None of them have large health-system expenditures ... Their

types of funding and organisation are extremely varied...”

A 2nd final critical point of view


•“The principal values reproduced in the WHO report are those that sustain the dominant conventional wisdom in the foremost medical, financial, and political arenas in the USA and other major more-developed countries, based on two main assumptions”. •“The first is the belief that the most prominent health problems our societies now face can be resolved by technological-scientific medical bullets or interventions, without reference to changes in the social, political, and economic environments in which these problems are produced ...”•“The second assumption is that the supposed “failures” of health-care systems are due to an excessive reliance on public interventions without allowing for the development of the (assumed) great potential of the private sectors... “•“This conventional wisdom has become almost a dogma, which, like all dogmas, is based more on faith than on evidence. It is wrong for the WHO report to uncritically reproduce this thinking”.

A 2nd final critical point of view


Labai achiu

Muchas gracias

Spanish national healthcare system

Health & Medicine

salud healthcare areas

regional healthcare

mental healthcare

salud healtcare centers

salud zona

salud bucodental

salud cisns

copayment system