sou · H0B333 · 2012-05-15 00:00:00 — The reform aims at reducing hospitalization especially of elderly patients by intro- ducing low threshold units in primary care as an alternative to hospital treatment. Such wards have existed in some city munici- palities to facilitate rehabilitation of elderly patients after acute hospital treatment and these are considered successful in improving the quality of care for these patients. This measure might therefore lead to some rationing of hospital resources to elderly patients. As pointed out, reforms so far have not yet tackled explicitly any of the fundamental policy issues to make health care more sustainable for a progressively ageing population, such as for instance the criteria and processes and responsibility for deciding public coverage of services and rationing of care and priority setting. These are considered contentious questions which are often played down in the political debates due to concerns about electoral preferences which are often more local in nature and often drive political interests (, 2011). Implementation tools for the 2002 reform were the replacement of unconditional grants with earmarked funding, and the integration of hospital ownership and funding into one administrative layer. Hospital merger has been a prevailing tool related with allowing a more centralized administration of hospital providers at regional level. The number of local health authorities (essentially hospitals) was substantially reduced from 55 in 1999 to 21 in 2011 and now closely resembles the number of counties. The merger occurred mostly through merging single hospitals into larger enterprises; for instance in , four smaller hospitals were recently merged into one hospital trust. The reform and especially the merger of hospi- tals has not been uncontroversial especially amongst trade unions, but hospital managers and hospital staff has not substantially resisted implementation of the reform, as they form part of the public sys- tem with relatively limited autonomy. New arrangements for promoting the coordination of care will be implemented in 2012. The coordination reform adopted by the Storting, the Norwegian Parliament, in 2011 aims at promoting primary care treatment settings over hospital care especially for the elderly population and incentivize earlier hospital discharges. The plan is to use financial incentives for municipalities (who are respon- sible for primary care, long term and rehabilitation care) to retain treatment in the primary care setting: from 2012 onwards, half of the activity related funding for hospital care, which amounts to overall about of funding compared to a funding through a fixed budget, will be allocated to municipalities for co-funding general hospital admissions and the hospital budgets will be re- duced accordingly. Low threshold pre-hospital wards will be estab- in primary care settings by 2016, and primary care institu- tions will be charged a penalty fee for not receiving patients ready for hospital discharge and in need for long term or rehabilitation care. The debate about the distribution of funds amongst the 5 regional health authorities was initially one of the major constraining fac- tors in implementing the 2002 hospital reform, due to the lack of consensus on the methods for distributing funding and the redis- tribution effect of the different methods. An initial capitation based model recommended by a first government-appointed commission failed to obtain the agreement by the due to concerns over favouring certain county models. A second committee finally lead to an agreement for another capitation based distribu- tion model in 2009 (, 2011). The reform did not lead to the expected improvements on defi- cit budgeting at the initial aftermaths of the reform, since 4 out of the 5 regional health authorities ran substantial deficits and it took until 2009 when the regional health authorities managed to secure small budget surpluses (, 2011). In addition, the reform did not yield any economic savings, on the opposite, hospital expenditure is said to have doubled since (Romøren et al., 2011). The governance model for hospitals is subject to considerable con- troversy after 10 years of implementation of the hospital reform. Only one of three parties in the government coalition (the Labour party) defends this model. Recent surveys show that equity may not have substantially improved and that waiting times have increased. It is thus not unlikely that the system will experience some further changes in the near future (, 2011). A reversion back to the decentralised model with counties in charge of specialist care prior to the 2002 reform is very unlikely. One of the more probable options seems to be the abolishment of the regional health admini- strations to further strengthen the national level policy capacity, for instance through a direct governance role of the ministry of health or the directorate of health on the 22 local health autho- rities/hospitals. The merger of hospitals means also a substantially lower number of hospital actors, so that a delegation of responsi- bility from the state to the local level is more reasonable compared to the situation in 2002 (, 2011). Another argument in favour of a more centralized governance form is that the resource allocation model would not change with the abolishment of the regional health administrations since the local authorities receive their funds on the basis of the same capitation model as the regio- nal health authorities (, 2011). A related option is the adoption of a national health plan as a more detailed policy tool guiding priorities, resources and expected outcomes for health and health care. It is also likely that municipalities will merge to create economic of scale benefits in delivering primary and long-term care to a larger catchment population. But centralization is not likely to affect municipalities principal responsibilities for primary health care and long term care and centralize it at the level of the state since this would trigger strong resistance and might be too much of a dramatic shift away from traditionally decentralized health system culture (Romøren et al., 2011). Governance model and recent changes The current configuration of the Spanish NHS was created during the transition to democracy after death in the mid-1970s. In the brief time-span of a decade to the mid-1980s, was transformed from an authoritarian, centralist regime to a demo- cratic decentralized state. Political power was substantially devolved by the 1978 Constitution to 17 regions (Comunidades Autónomas, CAs) and two autonomous cities in northern giving them wide-ranging asymmetric autonomy as some CAs have more powers than others. The agreement was that a two-chamber Parliament, elected by direct vote, and a National Government would be at the centre of a federal-like system without federation. Central government would control certain policy areas (for example, defence and foreign affairs); CAs, through their own elected regional parliaments and governments would exercise their own legislative and executive authority over an increasing number of policy fields, including health (the protection of which was recognized as a Constitutional right). Outlined by the national constitution and the regional charters (Estatutos de Autonomía), therefore, CAs have constitu- tional responsibility over health in the post-Franco de las Autonomías (Autonomous-Regions-Spain). Public health and health care planning competencies were then transferred to CAs between 1979 and 1981 by common law. The General (1986) coincided with the entrance into Union and meant the formal transition from a system of social security (model) into a NHS (model) with a progressive transition from payroll contributions to general taxation as the main source of financing. The exception was three publicly funded mutual funds which cater exclusively to different sets of civil servants in government departments, the , etc. and occupy a unique quasi-public position (civil servants are free to choose between public provision within the social security health- care facilities network and fully private provision). In summary, in the last few decades central state competencies in have been transferred upwards to and downwards to Regions. The transfer of supra-national sovereignty to the Euro- 1 This section was written by . pean Union has been the same for all EU members and is not covered here. Decentralization to regions has had a far deeper impact than Europeanization. Health system decentralization has resulted in a complex balance (Durán A, 2011). There is no doubt in the public opinion (media reports, experts opinions, etc.) that central govern- ment is now much weaker than before, and the ACs are much stronger. The main tool used for the changes has been the law, supported by financial instruments. In health, the mandate as was shared between the centre (, Social Policy and Equa- lity, MSPSI) and the regions (Ministries of Health of the CAs). Professional organizations also contribute through ethical com- mittees, etc. In more detail, the designed division of responsibilities in health care was as follows: -Central government is expected to provide a common frame- work for health and health care in order to ensure equity, cohe- sion and common quality standards; -Implementation and service provision is the responsibility of CAs. Each CA has a regional health department and health minister responsible for health policy plus a health service which manages service delivery; -Health policy coordination between central government and CAs is done by an or Commission (Consejo Interterritorial) without executive power – it only provides consensus recommendations to promote cooperation and exchange of information towards equity, with represen- tatives from the central and each regional health department. In the field of service production, multiple public health care net- works (mostly municipal and provincial) had covered for decades in the charity-based system, infectious diseases monitoring and treatment, the previous network of rural primary care, most health promotion and prevention activities, psychiatric care and some community care programs (in total, approximately of total public expenditure on healthcare). They coexisted between 1948 and 1985 with a social health insurance system () financed by compulsory contributions covering first workers and later on their families (representing some of total public expenditure in healthcare). As indicated, the country merged all health resources in 1986 into a tax funded Sistema Nacional de Salud (national health system, SNS) offering coverage to all residents, including immigrants (only of the population, consisting of high- income, non-salaried individuals refuse to be registered.). Health services in primary health care were (and remain) provided by publicly salaried professionals (one doctor and nurse/every 1.500 inhabitants with numerous prevention programs) while of all available hospital beds were (and also remain) in the hands of the public sector – with directly owned and the remainder sub- contracted from the private sector, including of acute care beds, of psychiatric beds and of long-term care beds. Resources from traditional public healthcare networks were trans- ferred to regions soon after death in the late 1970s. The transfer of the social security institutions however was done on a step by step basis, visibly for the sake of and due to dis- agreements on its costing and related financing issues between the central state and regional governments. The process was far from problem-free. Up to 2001, the central government had devolved responsibility of the health care network to , Basque country, , , , and , which together cover approximately two thirds of the Spanish population. An SHI-inherited central institution, () remained managing services in the other ten regions. The decentralization reform was completed in 2002 and after almost twenty years of reform resulted in the governance being transferred to all 17 autonomous regions. The following diagram expresses the chronology of the first batch of health competencies decentralization (devolution) to autonomous communities: 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 ························· 00 01 02 03 04 05 Catalonia (24 years) (20 years) Basque Country and (16 years) and (14 years) (10 years) Rest of AACC (3 years) Source: , and , 2006, HIT, , page 20 Besides the Constitution, the Regional Autonomy Charters and the General as core laws, Royal Decree 63/1995 (lower range law) defined in 1995 the minimum benefits package to be offered by all regions; it was updated in 2003 through the Co- hesion and Quality Act, which also stipulated a number of areas where services had to be agreed upon by the . The last update, also establishing the mechanisms for inclusion of new common benefits, took place in . Regions are allowed to include additional services if they are prepared to finance them through their own budget, thus expressing the tensions between the principle of regional diversity/decision-making and the principle of and equitable access to health services. While some regional governments have enacted their own Regional Health Laws, others have used lower range legislative tools for developing a legal framework of their own. In financing terms, the 2001 Act on the of the Autonomous Communities (not explicitly a health law) set the new overall framework regarding the financing function of the NHS, after its approval through the high-level cial and Fiscal Policy. Transfer of funds from the centre to the regions is negotiated annually between the central govern- ment/CMoH and the regional governments /RMoHs. Looking at the percentage of revenue by source, public expenses in health represents of the total funding (of which taxation is , professional mutuality schemes and civil servants mutual funds ), out-of pocket direct expenses (mostly for pharmaceu- ticals) is and private insurance . On average, CAs health ministries (responsible for health policy) plus CAs health services (managing service delivery) jointly spend in of total public funds for health which are mostly not earmarked budget transfers from the state; the health budgets are also around of each CAs total budget (which also include education, unemployment benefits, etc). As a percentage of public funds spent on health, specialist care represents roughly of the total, pharmaceuticals almost , primary health care accounts for a bit more than , and prevention and public health some – with the remaining in the other category ( Armesto et al, 2010). As last cornerstone of the decentralization process in health, the above-mentioned SNS Cohesion and Quality Act (2003) ratified the principles of provision, equity in access to services, system integration and decentralization as founding principles of the Spanish (now regionalized) health system. The policy priorities were explicitly political: there was consensus that the process of health system decentralization would have posi- tive effects in . Since it was considered that all regions should enjoy the opportunity to offer services closer to where people live, there was a need for them to be first involved (inclusiveness) and then coordinated (supervision). Indeed changes – which coin- cided with a period of sustained economic growth before the financial crisis began in 2008 – encouraged flexibility and innova- tion in health services delivery, fostered approaches attuned to local preferences and stimulated investment in health care (Borkan J et al, 2010). Decentralization has certainly coincided with – and most likely contributed to – positive effects, including improvements in health outcomes. For example, now enjoys a high position in most world health outcomes rankings. It occupies a4th place in average life expectancy at birth (3rd for females), 4th in life expectancy at age 65 and 4th in rankings for female potential years of life lost. From 1970 to 2008 average life expectancy at birth rose from 72.88 to 81.24; infant mortality fell substantially from 20.78 per 1.000 live births to 3.35 over the same period (WHO EURO, 2011). also dwells among the lowest mortality rates for top causes (cardiovascular diseases, cancer and respiratory diseases) in Europe since 1970. The only area in which shows clearly worse out- comes is in diabetes-related lower-limb amputations, with 26.5 ampu- tations per 100.000 in 2006, compared with the average of 14.9 amputations. Reductions in avoidable mortality during the period 1991–2005 suggest that there is substantial healthcare access to and quality and safety of services (et al, 2010). A similar picture of improvement emerges for the five-year relative survival rates for selected cancers (breast, colorectal and lung) from 1990 to 2002, which are comparable to the advances made in , , and the (KantarHealth 2010). Importantly, such results have been achieved with what seems to be a very efficient level of expenditure in terms of international comparisons – in 2007 spent of its GDP (US$2671 per person) on health care, versus in the (2009). There is generally a high level of user satisfaction and system legitimacy according to national surveys also; for example, usually more than 2/3 of respondents consider that the SNS works quite well and works well yet needs changes (Agencia de Calidad del SNS, 2010). Another good product of the Spanish decentralization in health has been an unexpected explosion of semi-autonomous public hospital models – see case-study on in the recent Observatory book (and , 2011). On the minus side, geographical differences in health outcomes and financing as well as intra-region inequities have arguably changed: Healthcare decentralization in seems to show no positive effect on convergence in health, as measured by life expectancy at birth and infant mortality between provinces Some provinces improved their situation overtaking others but the final result is one of greater dispersion than at the start (Montero-Granados et al., 2007). Average life expectancy at birth for both sexes ranges from 82.5 in to 79.8 in and infant mortality in is reported to be less than half that in almost neighbouring (Federación de Asociaciones para la Defensa de la Sanidad Pública, 2011) – no doubt, differences in health status also reflect income and wealth differences so blaming the health system decen- tralization process only or entirely would be unfair – the issue is mentioned here mostly in terms of unfulfilled expectation. Decentralization appears to have kept per capita health expendi- ture uneven. Overall, however, in the period 1992–2009 the vari- ation coefficient of expenses among regions increased – and changes in population-protected volume fail to explain such variability (et al, 2010). Publicly funded health care expenses (budgeted) per person in 2010 still differed by 557 (i.e. of the average of 1.343) between the at of the average and the Basque Country (at ) and in 2011 are reported to be almost bigger in and Basque Country than in Baleares and . Different funds have been set up aimed at compensating diffe- rences in health needs and minimizing inequities. Since those diffe- rences were again acknowledged in 2003, the then final compen- sating mechanism was designed as follows: (i)two general funds – the , designed to finance investment projects to remedy economic imbalances among regions and the , intended to provide regions with the resources necessary to fully cover their needs, allowing to cover the gap between the funds re- quired and the funds obtained from tax revenues; (ii)two health specific funds – the and the . The first one is distributed among the ACs according to population covered. The second is aimed at guaranteeing equity in access to services for individuals who receive health care outside their region of , those who come to from other EU countries, and people from other countries that have signed reciprocal public health care agreements with . In practice, those moneys clearly failed to promote national cohe- sion and reduce inequality by addressing geographic inequalities. Legislation was passed again in to create a new regional financial system around a for Fundamen- tal . integrated the created by the SNS Cohesion and Quality and holds of the resources for key public services such as education, social services and health care; monies are collected centrally from tax revenues and then dispersed. However, critics argue that it was created in the context of electoral politics, and that allocation arrange- ments disproportionately serve the demands of some regions (namely Cataluña). In light of the above, there should be wonder that the Spanish health care system shows unwarranted variability in access, quality, safety and efficiency, across regions, health care areas and hospitals, including: -5-fold variation in the use of percutaneous transluminal coro- nary angioplasty (PTCA) between areas and 2-fold variation in mortality after PTCA (hospitals); -7.7-fold variability in prostatectomy rates across health care areas; -28 times more frequent admissions to acute care hospitals due to affective psychosis between health areas; -of hospitals with between 501 and 1.000 beds are at least more inefficient than the average; -of hospitals with between 201 and 500 beds are at least less efficient than the standard for treating similar patients (et al, 2010). The population does seem to perceive such lack of geographical equity in financing: only of respondents in the Health Baro- meter survey believe that the same health services are offered to citizens despite region of , compared with around who assess treatment is equal despite patient's gender and around who assess treatment is equal despite a patient's social class and wealth. In other words, regional devolution is rather clearly per- ceived as equity-adverse as per the diagram below; Source: Agencia de Calidad del SNS. de Información Sanitaria (2010) Barómetro Sanitario 2009. Paradoxically, devolution has had effect on SNS staff and patients/citizens voice on how health services are managed. While decision-making at the national level has been clearly decentralized, processes at regional level have copied the old-centre over-centrali- zation, with plenty of duplication of the delegation and account- ability chain. In addition, and remarkably so, [CAs] have been belligerent against municipal powers and have tried to grab their competences (, 2003). Wrong patterns of decentralization have also been quoted as the cause behind the complex relationships between regional admini- strations and the profession. Health services management in was born in an unfavourable context: obsolete public administration, bureaucratic inheritance, lack of qualified human resources In spite of it all, a modernizing wave gave birth to a spectacular improvement But while this generation of enthusiastic managers improved facility and service management, they did so at the expense of enforcing a centralist model tainted with enlightened despotism, sidelining away from power even the influential leaders who rather informally but effectively had led life in the big public institutions for decades –especially in big hospitals (Belenes, Other problematic aspects of decentralization include an infor- mation deficit and very limited connectivity across the country and between regions: regional health systems have developed an enor- mous variety of sophisticated information systems (including electronic prescriptions, etc) but they are not necessarily compa- tible with each other.