1. Health System Decentralization in Spain Dr. Antonio Durán London School of Economics 14 September 2010

2. Main topics to be addressed - Division of competencies, - Political reasons behind devolution, - How it works in practice; - Results

3. 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.comhttp://www.ine.es Total population 46,157,822 Foreign population 5.268.762 (non UE 60.1%) Fertility rate1.46 children per woman Literacy rate97.8% GDP (2010 est.) 1,422.1 US$ billions GDP per capita (2010 est.)30,565 US $ at PPP Recorded unemployment 19.8 (2010 est.)

4. 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.

5. 197019801990200020052008 (*) Life expectancy at birth, female 75.5178.6480.5783.0383.8084.27 Life expectancy at birth, male 70.1472.4673.4275.9577.0978.17 Life expectancy at birth in yrs 72.8875.67779.4980.4481.24 Infant deaths/ 1000 live births 20.7812.417.64.383.783.35 Summary health indicators 1970-2008 (selected years) Source: European Health for All Database, May, 2010 (*) Instituto Nacional de Esadística, May 2010

6. 1991–2005 reductions in avoidable mortality suggest substantive access, quality and safety 1991199620012005%change 3 Mortality in primary prevention sensitive conditions 1 Total568.5458.1447.0391.1-31.2% Male861.9697.2686.7609.7-29.3% Female237.2187.7181.5154.5-34.9% Mortality in medical care sensitive conditions 1 Total138.6108.388.779.6-42.6% Male155.1119.594.884.8-45.3% Female120.195.582.074.0-38.4% Years of life potentially lost (1–70) 2 Total49.344.436.532.8-33.5% Male64.763.651.746.2-28.6% Female24.725.121.219.2-22.3% 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]

7. Selected cancers. Five-year relative survival rates EUROCARE–42 EUROCARE–43 1990–19941995–19992000–2002 Breast (women)France80.9%82.7%N/A Germany75.8%78.3%78.7% Italy79.7%83.7% Spain76.2%80.8%82.8% UK (England)72.4%77.6%77.8% ColorectalFrance56.7%57.5%60.3% Germany52.4%57.5%61.4% Italy51.9%57.4%59.5% Spain50.5%52.5%61.5% UK (England)45.9%50.8%51.8% LungFrance14.0%12.8%N/A Germany11.7%13.2%14.1% Italy10.8%12.8%13.3% Spain11.4%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.

8. -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

9. 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 67,4 68,1 69,2 56 58 60 62 64 66 68 70 1995….200720082009 Years % of respondents

10. Health expenditure as % of GDP, selected European countries 2008 Joint OCDE, WHO and EUROSTAT National Health Accounts, www.who.int/country/en, June 2010 www.who.int/country/en 3,7 4,7 5,2 6,5 6,6 6,8 7,2 7,3 8,4 8,6 8,7 9 9 9,1 9,7 9,9 10,1 10,4 10,5 11,1 024681012 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

11. 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)http://www.irdes.fr/EcoSante/DownLoad/OECDHealthData_FrequentlyRequestedData.xls 1960196519701975198019851990 Australia 99 127 219 463 696 998 1,310 Austria 69 94 172 389 716 984 1,383 Belgium 55 84 135 320 607 879 1,242 Canada 109 155 264 457 773 1,244 1,811 Denmark 70 125 226 363 618 807 1,051 Portugal-- 48 166 265 398 554 Spain 14 38 87 198 342 452 774 Sweden 94 151 285 496 897 1,150 1,455 Switzerland 96 141 281 541 886 1,224 1,640 Turkey--- 39 67 66 133 United Kingdom 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 2283 2671 3323 4417 651 2992 7290 2840 3601 3424 3588 2727 3319 3049,5*

12. 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 %

13. 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

14. “Federal-like” system… without Federation 17 Autonomous Communities 2 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

15. 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). (Cohesion and Quality Law. 2003)

16. But problems with (i) Geographical differences in health outcomes and financing (ii) Large unwarranted variability in access, quality, safety and efficiency

17. 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 http://www.msc.es/estadEstudios/estadisticas/inforRecopilaciones/docs/Indicadores2009.pdf 79,5 79,8 80,4 80,5 80,6 81 81,1 81,5 81,6 81,7 81,8 82,1 82,5 757677787980818283 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

18. 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)

19. 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 País Vasco1623 Extremadura1609 Navarra1543 Asturias1507 Rioja1443 Aragón1419 Castilla-León1360 Cantabria1347 Castilla la Mancha1346 Murcia1334 Galicia1333 Cataluña1298 Canarias1295 Andalucía1180 Comunidad Valenciana1122 Madrid1108 Baleares1066 Public health care expenses per person, 2010 (budgeted)

20. “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

21. 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(%)

22. Sustainability concerns… (> 130% growth in capital expenditure in 2000–2008!) Trends in health care expenditure in Spain, 1980 - latest available year 198019851990199520002005200620072008 ( *) Total expenditure on health, per capita $US PPP 363496872119315362267246626712791 Total expenditure on health, % of GDP 5.35.46.57.47.28.38.48.58.7 Public expenditure on health % total expenditure on health 79.981.178.772.271.670.671.271.872.8 Private insurance % total health expenditure 3.23.7 3.43.95.96.05.9n/a Out-of-pocket payments % total health expenditure n/a 23.6 22.421.521.020.3 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.pdfhttp://www.ecosante.orghttp://www.who.int/nha/country/esp.pdf

23. 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

24. “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

25. 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

26. 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… 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 Percentage 2007 2008 2009

27. Public sector staff uncertain numbers. Health care personnel/100000, 1980– 2007, selected yrs Staff, 100.000198019901995200020052007 Physiciansn/a369.8247.4316.4376.8375.6 Physicians, some specialties n/a30.933.439.746.3n/a Dentists10.526.635.743.751.056.2 Pharmacists62.159.063.581.294.7n/a Nurses316.2406.8576.9642.2741.5n/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

28. 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

29. 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

30. 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