Advocates for Evidence-Based Health Policy Speakers
Lessons From the Spanish Health System
After the fall of the dictatorship of Francisco Franco (1939-75), Spain took on a rapid reorganization of its health care services.
After Franco, health protection and care was declared a right of every Spanish citizen and a universal, general, and free national health system became the national goal. The central government sets basic principles by means of national standards and pharmaceutical policy.
Jurisdiction over health care is distributed amongst Spain’s 17 Autonomous Communities (similar to states in the United States) that control health planning, public health, and management services. Autonomous Communities are divided into Health Areas that are responsible for management of facilities, health services and benefits, and each Health Area is composed of several Basic Health Zones that are organized around a single primary care team. The Basic Health Zone coordinates prevention, promotion, treatment and community care activities for its 5,000-25,000 inhabitants. This transformation included a shift in basic financing from a social insurance model to one that is tax-based. An estimated 15 percent of the population maintains private supplemental insurance, but the majority of care is publicly funded.
Outcomes have been positive. In 2007, Spain spent $2,671 per person (8.5 percent of GDP) on health care, below the OECD average (8.9 percent of GDP) or that of the United States (16 percent of GDP). Spain also ranked 6th in life expectancy among 30 OECD industrialized democracies and 17th in infant mortality out of 224 nations. From 1986 – 2006, mortality from disease of the circulatory system decreased from 322.1 to 159.0 per 100,000 population, adjusted for age. Deaths from diabetes mellitus also declined during the same period, from 19.8 to 12.5 per 1000,000 population, adjusted for age.
Eight major principles have been accredited for the success of the transformation:
1) Stronger Primary Care – Family and Community Medicine was established as a specialty with the mission to promote comprehensive health care. Spain also set as its goal that there be a primary care center within a fifteen minute radius of any place of residence, establishing multidisciplinary primary care teams that offered a broad range of services. By 2008, these teams now handle more than 70 percent of all health care visits in the country.
2) A Voice of Citizens – Public forums are held in order to not only engage, but to also communicate about time and resource constraints. Technological systems included phone, email, web, TV, DVD and text messaging are also used to communicate with patients.
3) Electronic Health Records – A comprehensive system will be fully accessible in every region by the end of 2010.
4) Community Pharmacies – New regulatory criteria for the opening of pharmacies has been enforced in order to achieve greater equity and access.
5) Regional and Local Levels – Each branch of the system is provided some autonomy within the implementation of national guidelines.
6) Best Practices – Multiple demonstration projects are in place in order to redesign clinical processes and to share lessons learned.
7) Systemwide Approach – The multiple actors within the health care system (e.g. physician groups and practices, hospitals, and specific health insurers) are involved that transcend traditional geographic, sector and institutional boundaries.
8 ) Sustained Commitment – Spain’s political leadership has adopted a bipartisan approach to the stable funding of a universal access system.
Commentary
In addition to its common national structure, the final two principles greatly distinguish Spain’s advancements from those of the United States. Steps towards comprehensive health reform in the U.S. traditionally rely on change pertaining to single institutions and/or players within the health care system – for instance, the recent reform focused on select issues pertaining to health insurers but neglected to address the involvement of pharmaceutical companies, the courts, and other parties.
A holistic approach must be adopted in order for successful and widespread health reform to take place. There was little agreement between the controlling American political parties of Republicans and Democrats. Singular issues were highlighted with the outcome being that everyone had to “choose sides” instead of working towards a common goal. As noted in Spain, perhaps an initial discussion and fundamental acknowledgment of health care as a right and/or other basic principles is necessary to provide our government with direction.
by
Kameron L. Matthews, MD, Esq.
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