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The 1978 Spanish constitution laid down the rights of all Spaniards to health and to health care. It also established regional governments and a process of profound political decentralisation. Seventeen autonomous regions were formed, with sizes ranging from 5045 km2 in La Rioja to 87500 km2 in Andalusia, populations ranging from 263644 in La Rioja to 7238459 in Andalusia (1998 census figures), and population density ranging from 21.6/km2 in Castille-La Mancha to 634200/km2 in Madrid. Each region has its own cultural, socioeconomic, and historical identity and some regions (Catalonia, the Basque country, and Galicia) have their own languages.
In 1986 the General Health Service Act established a national health system with 17 autonomous health services. The main principles of the system were universal coverage, public financing through taxation (and, until recently, through social security funds to some extent), integration of existing health service networks, political devolution to the autonomous health services, and a new model of primary care with multidisciplinary teams based in health centres. The act has not yet been implemented fully.
The pace of devolution in health care has been more rapid in some regions than others, partly because the regional governments also had to take on social security functions. Only seven of the 17 autonomous regions (figure)—Catalonia, Andalusia, the Basque country, Valencia, Galicia, Navarre, and the Canary Islands—have taken over health care from the central body, the Institute Nacional de la Salud (INSALUD). The remaining 10 autonomous regions, covering about 40% of the Spanish population, have little or no control over their health services. They can make some health laws and can plan services, but lack of real power and of local money prevent them from implementing these plans. Within and among these 10 regions there is considerable variation and inequality in health and healthcare provision.
Complete transfer of power from INSALUD, when it finally happens, should bring Spain’s citizens closer to decision making on health. But there is still a long way to go, even in the seven regions with health care devolved to the regional governments. The health councils that were intended to control the system locally have not got going yet, and decentralisation has not reached the level of health areas and towns.
Another problem is the lack of an adequate formula for funding health care in the autonomous regions. The global budget for health is approved annually by the Spanish parliament, then allocated to INSALUD and the seven autonomous regions. The regions have legal powers to increase local taxes (never popular) or to transfer funds from one programme to another (for example, from public works to healthcare or education). But only Navarre and the Basque country, two regions that have historical rights of privilege and have long collected their own taxes, have used these powers.
Spain spends 6-7% of national income on health services. Distribution to the autonomous regions depends on population size but barely takes into account demography, population density, or morbidity and mortality. In 1998 the Consejo de Política Fiscal y Financiera, the national council for finance and taxes, decided that three other factors should determine the distribution of health funding: declining economic status of some communities, health service referrals from other regions, and the presence of “centres of excellence” and teaching institutions. These factors have not helped to make the system fairer. The last factor simply reinforces inequity and inequality: better hospitals get more money and areas lacking good hospitals have no chance of establishing new ones. Similarly, even though Catalonia is not the region that receives most patients from elsewhere, it receives 10% more money per person each year for health than the mean funding for the other areas, mainly for political reasons. The Catalan Nationalist party has 20 deputies in the Spanish parliament, on whose votes the central government depends for its parliamentary majority.
Variable control and funding of health services across Spain has fragmented care. There is considerable variation in provision. For example, schedules for child immunisation vary among the autonomous regions, and some include haemophylus influenza B vaccine. Some regions, like the Basque country, offer services such as dental care. Andalusia pays for some drugs not paid for by the other regions. In Catalonia the new model of primary care has been only partly implemented.
Devolved health care has led to the growth of regional bureaucracies; it is hard to show the need for these. In the absence of good coordination between the autonomous regions, there is duplication: for instance, there are four schools of public health and three agencies for technological evaluation. Contractual conditions and salaries of healthcare staff vary widely. Lack of coordination and cooperation seems to have reinforced the existing inequalities in health in Spain (table).1
Regionalisation of health services has not been an entirely negative experience. But for decentralisation to succeed more fully, citizens and professionals must participate more actively in healthcare policy making. The funding formula must be based on the health needs of the populations, and regional governments must maintain a good balance between autonomy and cooperation. These essential components are as yet almost completely absent in Spain’s health system.
Editorials by Leys and Diderichsen
Competing interests: DR-C is a member, and MS-B is president, of the Federación de Asociaciones para la Defensa de la Sanidad Pública (FADSP; federation of associations for the defence of the public health service).