Constitutional guarantees to health care in Spain.

The Spanish Constitution of 1978 required the founding of a compulsory national health care system with equal access to preventive, curative, and rehabilitative services. In 1986, the National Health Care Act extended universal coverage to all uncovered citizens, transferred the management of centralized INSALUD to the 17 regional governments, integrated regional and local governments, provided a network of primary care health centers, and changed the financing structure. Presently, 98 percent of the population is covered. In some geographically isolated communities, health care is very limited.

Buildings (Hospitals)

Present System

Bed distribution is very uneven, with more in urban and relatively well-to-do areas. Contrary to the situation in most countries, the public sector is better developed and more efficient than the private sector. The public sector owns 43 percent of the hospitals and accounts for 70 percent of the beds. Although the public sector is better developed, the upper social classes seek care in private hospitals at a rate seven time that of the lower classes.

Hospital Beds

There are 976 hospitals with 181,794 beds and an average size of 186 beds. Psychiatry has 111 hospitals with 35,273 beds and an average size of 318 beds. General hospitals, of which there are 422, have an average size of 268 with 113,141 beds. Specialty hospitals, of which there are 443, have 33,380 beds and an average bed size of 75. INSALUD owns 179 hospitals with 56,266 total hospital beds, 27 percent of total beds. Private hospitals sublet some of their beds to the public sector. In 1988, there were 4.4 inpatient beds per 1,000 inhabitants, 1.2 inpatient days per capita, 9.4 percent admissions as a percentage of total population.

Length of Stay

Admissions are related to income levels. Waiting times are greater for lower socioeconomic levels. In 1988, the average length of stay was 13.1 days and the inpatient occupancy rate was 76.4 percent.

Costs

General

In 1988, of the 7.11 percent of GNP spent on health care, 0.51 percent was for long-term care, 0.48 percent for dental care, and 0.12 percent for other services.

Equipment

In 1988, of the 7.11 percent of GNP spent on health care, 0.31 percent was for medical aids and appliances.

Hospitals

Hospitals are reimbursed on a per diem rate. Operating expenses are 90 percent of total hospital costs, half of which are salaries and wages. Hospitals owned by the social security system fund operating costs on a historically determined global basis. Case mix payments based on U.S. DRGs and Patient Management Categories (PMCs) are presently being tested as a form of reimbursement. Barcelona is one of the most advanced areas, with allocation models now in place. Hospital physicians are salaried. Hospital incentive bonuses are based on seniority, dedication, etc. Less than 10 percent of all hospital patients pay for their own care. The care of the rest is funded by Social Security or the insurance funds. In 1988, of the 7.11 percent of GNP spent on health care, 3.23 percent was for hospitals.

Insurance

The National Health Insurance scheme, which is financed directly by premiums, is called the Seguro Obligatorio de Enfermedad (SOE). Premiums for the National Health Insurance are from employers, employees, and a small government subsidy. In 1987, public insurance paid for 84 percent of hospital care and 77 percent of medical goods.

Medications

In 1981, the private sector accounted for 21 percent of the total market (32.019 billion pasetas) and the public sector 79 percent (120.453 billion pasetas). In 1982, Spain spent U.S.$1.4 billion on medications. In 1988 total spending in billions on pharmaceuticals was $2.47 which was $63 per person compared to $33.2 in 1977. in 1988, hospitals accounted for 12 percent of medication spending, physicians accounted for 76 percent, and 12 percent were purchased over the counter. In 1988, of the 7.11 percent of GNP spent on health care, 1.3 percent was for drugs, which is approximately 3 percent of the world market.

Patients

Patients pay 25 percent of pharmaceutical costs, and generic drugs are promoted. Drugs and some prosthetic appliances are the only part of health care where there is a copayment, with the elderly exempt.

Physicians

All personnel who work for the National Health Insurance program are salaried in hospitals or salaried plus capitated in the ambulatory sector. Physicians are reimbursed by the number of insurance cards in their panels. In 1988, of the 7.11 percent of GNP spent on health care, 1.15 percent was for physicians.

Drugs (Medications)

Approval Process

Approval of a medication must pass requirements proposed in August 1963 and modified in March 1970, May 1973, and November 1977. Clinical trials are not required and are left to the discretion of the medication manufacturer.

Availability

In 1980, only 41 percent of prescribed medications had demonstrated efficacy. In 1982, 9.6 medicines were prescribed per person on an outpatient basis and generic drugs were promoted. Of total spending, a great majority is for antibiotics and chemotherapeutic agents. The high cost of medications may preclude some usage. Consumption of medications in defined daily doses (DDD) per 1,000 inhabitants per day was highest for psycholeptic drugs, with all other medications far behind. The Spanish formulary has 8,000 trademark medications, with 18,000 preparations used because of different dosages and preparations. Almost 60 percent of medications are fixed dose combinations. Physicians use the Vademecum Daimon, which is produced by the drug companies and is the equivalent of the Physician's Desk Reference used in the United States.

Personnel

In 1984, pharmacists dispensed 11.3 medications per capita. There were 35,141 pharmacists in 1989, 87 per 100,000 population.

Finances (Funding Care)

Private Funding

The system is partially funded (90 percent) from contributions from the insurance sector. The employer portion of the national health insurance package is 70 percent and the employee portion is 20 percent. Of the 6.3 percent of GNP spent in 1984 on health care, 26 percent is private.

Public Funding

The system is funded from the general taxation pool. The National Health Care Act of 1986 established a fixed portion to be paid from Social Security, with the remainder paid from general taxes. It is difficult to determine the amount of health care financed by Social Security, as it also finances pensions, unemployment, other subsidies, etc. In 1984, health expenditures were approximately 28 percent of the social security budget. Of the 6.3 percent of GNP spent on health care, 74 percent is public.

Cost Controls

Cost containment has come at the expense of resource investment. The basic health care infrastructure is deteriorating. Certain population groups are feeling the brunt of this more than others.

GDP versus GNP

GDP

In 1990, Spain spent 6.34 percent of its GDP on health care, whereas in the previous year it had spent 6.3 percent on health care. The change in health expenditures as a percentage of GDP change was 44 percent from 1970 to 1980 and 14 percent from 1980 to 1989. The real GDP elasticities of health care expenditures from 1975 to 1984 was 2.1.

Per Capita Spending/Income

In 1989, per capita spending on health care in U.S. dollars was $644 and decreased to $520 the following year.

Health Care Providers (Physicians)

System of Care

In 1988, there were 131,684 physicians which is one physician per 296 inhabitants. This increased to 143,808 in 1989 and a ratio of 355 physicians per 100,000 population. Spain has the highest physically population ratio in Europe. The majority of health care providers are in Social Security establishments (53 percent of the total physician population. This resulted in approximately 6,000 unemployed physicians, 4.6 percent of the physician population. Junior doctors on the average worked 60-69 hours per week. Health care providers who see patients in the public sector frequently solicit the good paying patients to see them in the private sector. Patients who use the private sector are still free to use the public sector at will. The medical societies and profession held a very strong position until the early 1980s. Emergency services are available in areas with more than 5,000 insurance cards

Primary Care Physicians

Everyone is assigned to a primary care physician who is linked to a defined group of specialists. Physician panel size may vary from 700 to 1,200 insurance cards. The physician is reimbursed according to the number of insurance cards in his or her panel. Because an insurance card insures an entire family, the panel size and reimbursement per patient will vary. Administrative work load for this and many other tasks is a common complaint among primary health care providers. In the primary care centers, a primary care physician sees a patient every three minutes. These are termed "consultations."

Specialists

All referrals to specialists require GPs or pediatricians. The specialty referral hierarchy is one general surgery, ophthalmology, ENT, trauma, GI, pulmonary, and cardiovascular physician per 20 GPs; one radiologist and clinical analyst per 25 GPs, one gynecology, urology, dermatology, and neuropsychiatry physician per 40 GPs, and one endocrinologist per 70 GPs. Specialists account for almost 60 percent of all physicians. They almost all have at least small private practices. In the primary care centers, specialists see a patient every seven minutes. These are termed "general medicine consultations."

Other Health Care Providers

In 1984, there were 142,542 nurses, 7 per 100,000 population. Fifty-five percent were females, and 53 percent were located in provincial capitals. In the same year, there were 5,770 nurse midwives, 2 per 100,000 population. Seventy-three percent were female, and 65 percent were located in provincial capitals.

Insurance

Administration

Private insurance, which is held by 17 percent of the population, allows access to private physicians and private hospitals. In 1978, the Instituto Nacional de la Salud (INSALUD) was formed for the sole purpose of management of the Social Security medical care services.

Health Benefits Package

Private insurance is usually for elective surgery and minor treatments.

Life Expectancy

In 1991, the average lifespan was 76.5 years, 73.2 for men and 79.7 for women.

Morbidity/Mortality

Infant Mortality

From 1980 to 1989, infant mortality decreased from 12.3 to 7.8 deaths per 1,000 births. Perinatal mortality decreased from 14 to 10.0 from 1980 to 1989. There are 11 maternal deaths per 100,000, which is relatively high.

Morbidity

Although the country is westernized, there is still a problem with infectious diseases and diseases of cleanliness that leads to epidemics. There is also a class distinction in abuse of alcohol and tobacco, with the upper classes consuming less than the lower classes, as is found in most countries.

Causes of Death

As in most westernized industrialized nations, the leading causes of death are from circulatory system diseases, neoplasms, and respiratory diseases. Deaths due to heart or cerebrovascular diseases are 46 percent of the total, and 21 percent of the total is due to cancer.

National Health Care Structure

National Medical Structure

A national sickness program called the Seguro Obligatorio de Enfermedad was made mandatory in 1942. It was managed by the Social Security System and paid by the workers. The National Health System was established in 1987 after many modifications over the years. Its major function is to manage, define responsibilities, define boundaries, and coordinate health care entities. Prior to the formation of a health ministry, there was a conglomeration of health care structures, most of which acted autonomously. The Ministry of Education had teaching hospitals associated with medical schools, the Ministry of Justice a health care network, the military a health care system, and the private sector numerous hospitals and other health care institutions. Preventive medicine and public health is in its infancy in the country.

Provincial Medical Structure

Presently there are 17 decentralized autonomous areas (Comunidades Autonomas) that follow previous regional boundaries. Responsibility for health care was transferred to the autonomous regions starting in the 1980s. Unfortunately, the authority has not yet been transferred from the Madrid central office to these areas. By 1991, decentralization had resulted in only six autonomous areas that supply health care to 57 percent of the population accepting responsibility for health services. Within each autonomous areas, care is divided into three systems. The first system is composed of three subsystems of general care (SS/INSALUD, provincial councils, and psychiatric hospitals and municipal care for the poor and indigent). The second system is public health activities with two subsystems. The third system is private, serving mainly upper-income populations. Each of the systems has its own central authority, independent administration, and a structure that is unique to that system.

Community Medical Structure

Prior to 1975, local governments developed care for the indigent, maternity care, psychiatric care, and public environmental health programs. INSALUD tried to develop Primary Health Care Centers and, by 1983, had established more than 1,000 centers and had employed almost 50 percent of total health personnel. Community participation in these programs is weak and diminishing.

Population

In 1990, Spain had 40 million people; 12.4 percent of the population is over age 65 and 2.5 percent is over age 80. The country is very polarized by region, social classes and the schism that usually exists between urban and rural dwellers. Over one-third of the population lives in provincial capitals that employ more than two-thirds of health care workers. There are more health care resources in the Northern part of the country than in the Southern part. Spaniards have a low degree of satisfaction with their system. Almost all agree that more should be spent on health care. They almost all also agree that it should come from reallocation of present government spending and not from new taxes. National unemployment is a problem, approaching 20 percent.

University Systems (Medical

Schools/Training)

Medical Schools

Teaching hospitals for medical schools were built by the Ministry of Education. They are administered by the Ministry of Education and Science. In the past, there has been unlimited opportunity for physician training (in 1987, there were 47,678 medical students). This unrestrained number has led to physician unemployment and resulted in "numerus clausus." First-year entrants have been limited to 7,320 since 1979. As in most European countries, medical school training requires 6 years after high school. There has been a rapid increase in the numbers of women in all the health care fields.

Edward M. Mendoza, MD, MBA, FACPE,is CEO, Augusta Medical Managers, Augusta, Ga., and Professor, Department of Medicine, Morehouse School of Medicine. He is Immediate Past Chair of the College's Forum on International Medicine and Health Care. Bryn J. Henderson, DO, JD, is a management consultant, specializing in health care issues, in Orange, Calif.