LESSONS FROM THE SPANISH HEALTH CARE SYSTEM
Roland G. Simbulan
( The author participated in the Advanced Seminar for Managing Health Institutions at the Carlos III Institute of Health in Madrid, Spain, September 25-October 10, 2004, upon the invitation of the Spanish Government. This is his reflection of that trip visit. This article was originally published in the September-October 2004 issue of Bagumbayan in U.P.Manila )
More than a century ago, our national hero Dr. Jose Rizal, finished his medical training in Madrid, Spain which at that time had already colonized us for more than two and a half centuries. I would like to share the following observations and insights into the health care system of our country’s former colonizer.
More than any European country, health is the most important basic social service in Spain. Spain’s national health care ystem is regionally structured. Autonomous regions are given the full responsibility for education, health care, policing and taxation. At the base are the primary health care centers such as the one that we visited in Segovia. And then there are the hospital-based specialized care centers, both of which are managed by the autonomous regions.
The 17 autonomous regions of Spain wield the real power in terms of basic services, especially health care management: Andalucia, Aragon, Asturias, Baleares, Canarias, Cantabria, C. Leon, Castilla-La Mancha, Cataluna, Extremadura, Galicia, Madrid, Murcia, Navarra, P. Vasco, Rioja and C. Valenciana. Asturias, one of the autonomous regions, and historically a Socialist Party bailiwick, spends as much as 35 percent of its total budget for its health care system expenditures. Predictably, this region also claims to have the best health care infrastructure in Spain and one the the largest aging populations in that country.
Spain has a national health care sytem whose coverage is universal, that is, its citizen-beneficiaries are all covered whether they are rich or poor, employed or unemployed, and all this comes from national taxes. Much of the major reforms in the Spanish Health Care System occurred in the 1980s, when the source of health care benefits shifted from the social security system to the national budget derived from taxes, with a single but devolved public network of health care services.
Further reforms in 2002 included the integration of health care expenditure in regional block financing and where regions are given more powers of taxation. The national health infrastructure, through the central Ministry of Health and Consumer Affairs, does not allocate moeny for the regions, but acts as modulator and regulator. It is the Ministry of Budget that decides on the regional budgets based on population and a set of criteria. It is the independent regions that ultimately decide on their allocation for health expenditures and implementation of health policies and programs which are managed by the Minister of Health for the region. The huge investment in health care is said to be growing two to three times the national economy. A 60-40 ratio of the health budget is maintained in favor of primary health care over the specialized health care in hospitals.
At the outset, our seminar director, Dr. Alfredo Rivas of the Instituto de Salud Carlos III, stressed that health problems in Spain are caused not by lack of money or because of poverty, but because of misbehavior or misuse of resources by citizens that comes in the form of problems such as drug addiction.
Spain has created a National Referral Center for Paraphlegics, located in the city of Toledo, the Hospital Nacional de Paraplejicos, which is supported by a Fundacion del Hospital Nacional del Paraplegicos Para la Investigaciones y la Integracion. We also had the opportunity to visit a few national health institutions such as the Pediatric Hospital “Nino Jesus, ” The National Library of Health Sciences and the National Center of Oncological Research, all based in Madrid.
Blood transfusion centers in Spain are organized regionally. For instance, the Centro de Transfusion, Comunidad de Madrid, which we visited is the regional center for the autonomous Madrid region for the autonomous Madrid region for the collection, processing and distribution of blood components to hospitals. It assures that policies for donation and transfusion are properly implemented, and is likewise responsible for hemovigilance programs. Its director, Sra. Lydia Blanco, told us that the blood transfusion center for Madrid has, among its activities, the management of blood donation, the Apheresis program, HLA typing, cord blood bank, study and registry of bone marrow donors, haemovigilance and investigation. Like all the other regions, the Madrid Centro de Transfusion has several mobile bus units that ply the different parts of the region for blood donations from donors, all on a voluntary basis.
The efficient Information System for the Surveillance of Infectious Diseases(EPINE) has managed to keep nosocomial infections in Spain at a low 5-7 percent with an effective epidemiological surveillance of all infectious diseases. Despite the efficiency of health care institutions in the field of infection surveillance and prevention, tourism has had a telling effect on the health care system. Spain is next to Portugal in the number of HIV-AIDS infections in the European Union, and this has been attributed to the thriving tourism industry in the country, the worsening narcotics problem and the fast-rising number of immigrants.
The autonomous regions of Spain also maintain their own SUMMA 112 (Servicio de Urgencias Medicas de Madrid), that is known for its specialized rapid-reaction force for medical emergencies. It maintains a centralized call center for the region, and a fleet of vehicles, including special ambulances equipped with modern Intensive Care Unit facilities. Among its resources are its vehicles called Vehiculos de Intervencion Rapida(VIR), including 4X4 vehicles for the rural areas, helicopters and small boats. SUMMA 112 also provides its callers and citizens free medical advice, for those seeking this kind of service in non-emergencies. The efficacy of the SUMMA 12 was tested to the limit on March 11, 2004 when Spain experienced four simultaneous train bombing attacks in the heart of Madrid: El Pozo, Atocha, Sta. Eurgenia and Tellez Metro subway stations. All in all, there were 198 deaths and over 1,500 wounded. It could have been a much worse casualty figure had SUMMA 12 not responded so efficiently.
The Ley de Contratos del Estado (Spanish Law on Buying), the equivalents of the Philippine Procurement Act, puts premium on the minimalization of packaging to avoid the disposal of hazardous substances. The law is conscious of the products that may pose a risk to the environment like mercury products. Environmentally friendly thermometers and sphygmamometers are now being put to use in the entire health care system. As most of the health care institutions in Spain which are maintained by the autonomous regions are state-managed, the logistics and purchasing system is centralized from medicine and supplies. Thus, the objective of this supply chain is for materials, equipment and medicine to flow quickly to avoid excess of materials. The supply chain is optimized from the supplier to the patient, who is ultimately the end-user.
One of the dilemmas of a modernized health care system, such as that in Spain and the European Union, is the large number of the aging population in relation to the working adult population. The older population has increased because of improved medical intervention and technologies but there is less productivity and a greater burden for the economy. This is despite the continuing purchasing power of the retired and elderly. As much as 25 percent of health budgets are being allocated to support the aging population. More and more senior citizens are being supported by a smaller working and young population. This is now also a trend in the entire European Union where social economies or social welfare states are in crisis or are said to be at risk in terms of their sustainability.
One fact that stunned me during my study tour in Spain is the small difference between the compensation of medical doctors and nurses in Spain. This is so because most physicians and nurses in Spain work in hospitals or primary health care centers which are managed by the state, or in particular, the governments of the autonomous regions. In the case of doctors, their average pay is around 2,200 – 2,500 Euros a month while nurses receive an average compensation of 1,800-2000 Euros per month.
One thing I learned in Spain is that health cannot be left at the mercy of market forces. State invervention for health is needed, and a cost-usefulness analysis — not a cost-benefit analysis — is used for the health care system. It is estimated that, on average, 8 percent of the Spanish GDP is allocated for health, even though the World Health Organization’s (WHO) prescription is just 5 percent of GDP. Some of the autonomous regions of Spain like Asturias, have allocated as much as 35 percent of their GDP for the health care system.
The state’s responsibility for managing health, however, does not mean that a public-private partnership cannot be established. In the region of Madrid, a “crash plan” for infrastructural renewal to build eight hospitals at the same time has meant outsourcing with the “co-participation” of private business for the implementation of infrastructure projects, including maintenance. This includes the privatized management of non-health services in these public health institutions such as in local security, engineering, and parking. Here, private concessionaires are invited to tender through lease contracts that may extend for as long as 30 years. The objective is to lessen the pressure on public expenditures, thus result in less national debt. The entry of the private sector in public enterprises has in fact meant the reduction in the prices of medicine which is becoming even cheapter, a stark contrast to the skyrocketing costs of medicine in developing countries.
The National Health System of Spain has established specialized institutions for the training of health professionals. One of these is the Subdireccion General de Formacion y Difusion de la Investigacion Sanitaria del Instituto de la Salud Carlos III whose task is to train all health professionals in public health care and medicine and to manage the resources of the National Library of Health Sciences. Under this body is the Instituto de la Salud Carlos III (ISCIII), which is a self-governing body attached to the Spanish Ministry of Health and Consumer Affairs and is responsible for “the research, training and consultancy in areas related to Public Health and Health Administration.”
Health care is considered a right as well as a form of freedom. Health is regarded as a social service for all citizens, even those who cannot pay. The right to health care access for the rich and poor, young and old , is a common stand of the rival political parties in Spain, so much so that the health care system has been immune from the changes in the Spanish political system. Both the contending political parties, the former center-right Popular Party under Jose Maria Aznar, and the incumbent party in power, the Partido Socialista Obrero de Espana (PSOE), under the leadership of newly-elected Prime Minister Jose Luis Rodriguez Zapatero, have both given priority to the health care system despite the changes in the ruling party. Past PSOE administrations such as when Socialist Prime Minister Felipe Gonzales came to power in 1982 likewise gave priority to health among the basic social services. Other Spanish political parties both at the national and local levels like the Catalan Republican Left, the Basque Nationalist Party and the United Left are all known to support strong state support for the health care system, in their programs and deeds. In fact, the much-feared General Francisco Franco dictatorship, which ruled Spain for at least 40 years, was said to have begun a social security program in health for workers and built first-class hospitals for the people. Which just shows that a responsive health care system is the best indicator of social justice in any political and economic system.
The date posted here is due to our website rebuild, it does not reflect the original date this article was posted. This article was originally posted in Yonip in Sept 26th 2005