Spanish health care cuts: Penny wise and pound foolish?

doi:10.1016/j.healthpol.2012.02.001

Health Policy

Volume 106, Issue 1, June 2012, Pages 23-28

https://doi.org/10.1016/j.healthpol.2012.02.001 Get rights and content

Abstract

The purpose of this paper is to convey the specific health care actions and policies undertaken by the Spanish government, as well as by regional governments, as a result of the economic crisis. Throughout the last two years we have witnessed a number of actions in areas such as human capital, activity and processes, outsourcing and investment that, poorly coordinated, have shaped the nature of financial cuts on public services. This paper discloses the size and magnitude of these actions, the main actors involved and the major consequences for the health sector, citizens and patients.

We further argue that there are a number of factors which have been neglected in the discourse and in the actions undertaken. First, the crisis situation is not being used as an opportunity for major reforms in the health care system. Further, the lay public and professionals have remained as observers in the process, with little to no participation at any point. Moreover, there is a general perception that the solution to the Spanish situation is either the proposed health care cuts or an increase in cost sharing for services which neglects alternative and/or complementary measures. Finally, there is a complete absence of any scientific component in the discourse and in the policies proposed.

Introduction

The global economic crisis together with certain key internal aggravating circumstances have demonstrated the truth of the 2008 headline in The Economist “The Party is Over!” [1]. The Spanish government, and therefore the Spanish economy, has avoided intervention by the European Union, and although the country shows some relatively good indicators (public debt is 65.9%, 25% lower than the Euro Area average in 2010 [2]), it presents poor performance in terms of employment (22.6%, at the time of writing [3]), economic growth and public deficit [2]. It was not until late 2010 and 2011, however, that national and regional governments in Spain proposed major social spending cuts as a response to a dramatic rise in debt payment interests. Spain's cuts are taking place in a highly decentralised policy context, with 17 regional governments deciding on health care expenditures, as well as other social policy areas [4].

The purpose of this paper is to convey the actions and policies undertaken by the Spanish government as well as by regional governments, on health care as a result of the economic crisis and its consequences for the health sector, citizens and patients. In particular, the paper focuses on Catalonia, one of the regions more actively implementing cuts in public services.

Section snippets

Political and economic background

The international economic crisis has hit the public sector hard by constraining budgets allocated to all public activities including health care services. Expenditure on social protection in 2006 was 20.9% of the GDP, which placed Spain well below both the EU-15 average (27.5%) and the EU-27 average (26.9%). Per capita expenditure on overall social protection (including health) remains 2000€ below the EU-15 average [5]. According to the latest available data, total health expenditure is 9.5%

Actions

Over the last two years, we have witnessed a number of actions that have shaped the nature of financial cuts in public services. Overall, measures have been poorly coordinated, that is, isolated, incremental and opportunistic. There was neither a strategic approach nor a common framework for action. The following are representative of what has been done in this respect in three large areas: human capital, activity and processes, outsourcing and investment.

The central government recently passed

Actors

These changes and measures have been enforced by means of parliamentary decrees and governmental regulations in what can be argued to be a strictly top-down approach with no room for either professional or public participation. There is growing dissatisfaction among professionals for not being invited to participate in decision-making processes concerning cuts. Professional Trade Unions are channelling such indignation into street demonstrations, and professional associations and societies are

Consequences

The economic crisis will have an impact on citizen's health [27] although in Spain, to date, this has not been clearly quantified by health indicators [28]. Spain is among the countries with better health indicators relative to percentage of GDP spent on health care [29]. We can anticipate that these cuts will have a greater impact on patient satisfaction and comfort than on health itself, although, following the Greek experience [30], [31] further monitoring of the population's health is

What is absent from the discourse and actions?

We conclude that at least five elements have been neglected up to this point in time.

First, and most important, the economic crisis situation has not been seen as an opportunity for a major reorganisation in the provision of services, that is, as a positive shift in our traditional delivery patterns and inertias. We are witnessing a so-called path-dependency of previous decisions made in this area and we are incapable of any degree of divergent thinking. In brief, it appears as though we are

Conclusion

The economic crisis has forced cuts in public spending which are presented as necessary short-term measures. These actions are “penny wise” insofar as they have achieved their immediate goal, which is balancing annual budgets, but may prove to be “pound foolish” if they have greater costs in the future and do not contribute to improve the system. Measures implemented have resulted in a significant reduction in surgical and clinical activity, personnel redundancies, salary reductions, delay in

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Health reform monitorSpanish health care cuts: Penny wise and pound foolish?

Abstract

Introduction

Section snippets

Political and economic background

Actions

Actors

Consequences

What is absent from the discourse and actions?

Conclusion

Gaceta Sanitaria

Lancet

Lancet

Aten Primaria

Gaceta Sanitaria

Basic data; direct access

Spain. Health system review

Health Systems in Transition

Análisis comparativo de los principales impuestos en la Unión Europea, Estados Unidos y los países BRIC

Crisis y política fiscal. Diario digital El Plural, 18 de julio de 2011

Health reform monitor
Spanish health care cuts: Penny wise and pound foolish?