Post on 30-Jun-2020
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DESCENTRALIZATION AND HEALTH POLICY IN SPAIN Antón Losada
Paper for ECPR 2001 Grenoble Departamento de CC Política e da Administración
Facultade de Ciencias Políticas
Campus Universitario Sur
15782. Santiago de Compostela
Spain-España
teléfono 34 981 56 31 00
Fax 34 981 59 69 51
alosi@usc.es
Health policy has been highly decentralised in Spain during the last 15 years. Today
Andalusia, Catalonia, Galicia and the Bask country have their own regional health systems.
These regional services have implemented very different strategies and policies for
reforming the management of the health system. New instruments and solutions have been
implemented: the split between providers and buyers, introduction of internal markets,
implementation of new forms of organizations like foundations, private management of
public hospitals and so on.
These new policies and solutions have produced new models, ideas and solutions for
the public debate over health policy in Spain. Also, the decentralization process has
produced some kind of competition for resources and results between the regional
governments. Other important impact has been the creation of models for a demand for
change in the Spanish health system, in order to get the results and improvings apparently
provided by these new regional systems and policies.
The paper will evaluate if there are real differences of results and real differences in
terms of change and policies between this new regional services. Also the paper will assess
their impact and the real degree of improvement from the point of view of the consumers.
Also, the paper will consider the impact of this process of decentralization upon the specific
results and the concrete policies implemented by the different administrations. The paper
will try to get some answers for two very specific questions:
1. Are consumers better off after a process of intense decentralization of health policy?
2. Competition for resources and implementation of new policies are inherent
consequences of this process of decentralization of decision and management?
Health policies in Spain have experimented a period of rapid change and
transformation between 1980 and 2000. The main concern of this paper is to make a
description of such a process. We will try to explain it considering two main variables:
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a) Intentions, priorities and strategies of three main actors: professional, bureaucrats
and politicians wanted and fight for a change and for this concrete type of change.
b) The developing and consolidation of a totally new institutional setting. The Estado
de las Autonomías has created the opportunity for this change and, also, has had a
significant impact upon the type, timing and directions of changes.
1. PUBLIC HEALTH IN SPAIN: POLICIES AND ACTORS TROUGH TIME
A series of social security laws introduced, between 1962 and 1972, three main
changes in the very limited and residual public coverage of individual health care initiated
in 1940s, after the civil war:
1. Inclusion of health care in the social security system.
2. A significant increase in terms of public coverage.
3. The creation of a large network of public hospitals committed to provide public
heath care.
Health bureaucracy and professional mainly supported these changes. Economic
expansion and the need of Franco's regime to produce some kind of answer to the
increasing opposition create the opportunity to change traditional policies (Rico 1996).
The process of democratisation in Spain is also the process of extension and
consolidation of health as a universal right and as a public service. In 1978 four
administrative organizations are created in order to develop and extend a variety of health
and social service:
- INSS: to manage and develop a universal Social security system.
- INSALUD: to manage health services
- INEM: To manage and develop employment policies
- INSERSO: to manage and develop specific policies for old people.
These four organizations, heavily centralised and bureaucratised are responsible for the
massive extension and consolidation of the very limited social and health policies
developed till then by the Spanish state.
Following strategies and models taken for the British NHS, this four organizations
developed between 1980 and 1990 very big budgets and ambitious policies all over the
country and for all Spanish people: Nowadays the health coverage ratio is 99.79, but just in
1945, the heath coverage ratio was 22.06% of the population. In 1989 the right to have
health assistance become a universal right protected by law.
The following tables show some data about the actual state of health policy in Spain.
Specially referring to finance, resources and objectives.
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Table 1: HEALTH IN SPAIN: SOME INDICATORS (Source: MSC 1995)
LIFE EXPECTANCY INFANT MORTALITY
ANDALUCIA 76.0 7.7
CANARIAS 76.0 5.6
CATALUNYA 77.3 6.4
GALICIA 76.6 8.9
NAVARRA 78.1 8.1
BASK COUNTRY 77.2 6.7
VALENCIA 76.3 7.2
ESPAÑA 76.9 7.1
Table 2: HEALTH ASSISTANCE COVERAGE IN SPAIN (Source: ENS 1993)
Social security 94.7
Social security and Mutuas 2.4
Private insurance and Mutuas 2.1
Private insurance 6.3
Working Insurance 1.3
Charity 0.2
Private professionals 0.4
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Table 3: HEALTH FINANCING IN SPAIN (Source: Gest 1997)
YEAR STATE % SOCIAL SECURITY % OTHERS %
1986 23.8 74.3 1.9
1988 25.2 69.6 5.2
1990 68.8 27.2 4.0
1992 69.0 27.2 3.8
1994 70.2 27.1 2.7
1996 82.8 15.1 2.1
1997 91.9 6.0 2.1
Table 4: HEALTH SPENDING DISTRIBUTION IN SPAIN 1982-1995 (Source: Oficina de economía de las salud 1995)
YEAR GENERAL MEDICINE
AND PHARMACY
SPECIALISED
MEDICICE
OTHERS
1982 40.7 54.8 4.5
1985 39.6 55.5 4.9
1990 35.6 61.0 3.4
1994 33.2 61.7 5.1
1995 34.8 6.0 5.2
In 1981 health policies are split from working and labour policies. During its first years
in office, the socialist government begun a process of health care reform with five main
objectives:
1. The separation of heath care form social security
2. Financing of health services trough general taxation
3. Introduction of universal health coverage
4. Unification of the confuse network of public providers and regulation of the private
sector
5. Enactment of the basic state regulation and the institutional framework for
decentralization.
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In 1986 Spanish parliament passes the Health General Law. This law was the result of a
very hard process of negotiation and conflict between those who wanted to universalise
heath right as faster as possible -left wing parties, trade unions, left wing of Socialist
government, professionals- and those who were more concern with the cost of such a
process -right wing parties, nationalist parties, right wing of socialist government, health
bureaucracies-.
The main consequence of such a conflict was a very incremental and adaptative process
of implementation of health policies. In fact, 1986 can be considered the beginning of the
implementation of the health care reform. In a context of economic expansion and public
expenditure growth, significant progress was made in terms of
- Finance through general taxation
- Recreation and modernization of public hospitals and new health facilities
- Decentralization
During this decade begun a process of progressive decentralization of Health services
and management from the central state to the most significant regions:
- 1984: transfer of health policy and management to Andalusia
- 1987: transfer to health policy and management Bask country and Valencia
- 1990: transfer to health policy and management Navarre and Galicia
The timing of this process must be explained in term of two key variables:
1. Political factors: some regions like Andalusia wanted the decentralization process
done as soon as possible as a part of a global strategy in order to solve some
problems of identity or public perceptions about its utility as institutions.
2. Policy factors: other regions like Catalonia, bask Country or Galicia do not have
such a problem of identity or public perception. They prefer to negotiate carefully
the exact terms and conditions of the process, specially the financial aspects.
The beginning of 1990´s was also the beginning of a new wave of reforms. In a new
context of economic crises and public expenditure control and under a clear influence by
the models and ideas introduced by the Catalan Law of heath care Reform (1990), the main
objectives of this reform were:
1. Introduction of internal markets and new management
2. Separation of financing and provision through contract-programme
3. A more relevant and complementary role for private provision
4. Control of public expenditure
In 1996 the Spanish major right wing party, PP, won general elections with a
programme of reforms based on the ideas of liberalization, privatisation, reductions of
public spending and bureaucracy.
This political fact and the pressure put upon Spanish economy and Spanish public
sector by the European Union to meet the requirements economic integration have put even
more pressure upon this process of reforms, mainly in terms of:
- Privatisation of public facilities.
- Introduction of new management formula like contracting out, co-production and
co-payment of individual health care services.
The following table summarised this process of change and transformation. The table
tries to show which was the reference paradigm at every time, the type of policy
implemented and who were the main actors, -supporters and opposers-.
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Table 5 EVOLUTION OF PUBLIC HEALTH AS A PUBLIC PROBLEM IN SPAIN (Source: author)
Transition to
democracy
(1974-1982)
Socialist Decade
First half
(1982-1986)
Socialist Decade
Second half
(1987-1995)
First Popular
Government
(1996-2000)
Dominant
Paradigm
Universal right
Public provision
(NHS)
Universal right
Public provision
(NHS)
Vs.
Tachterisme
Mixed provision
Introduction of
internal markets
Management
Mixed provision
Introduction of
internal markets
Management
Privatisation
Supporters
Health
Bureaucracy
Health
Professionals
Health
Bureaucracy
Health
Professionals
Public opinion
Professionals
Moderate
nationalists
(CIU, PNV)
Private providers
Regional policy
communities
Moderate
nationalists
(CIU, PNV)
Private providers
Opposition
- conservative
parties
- left parties
-trade unions
-conservative
parties
-medical elites
-Private providers
relative:
-conservative
parties
-health bureaucracy
Strong
- Trade unions
-public opinion
Relative:
-left parties
- Trade unions
-public opinion
Position
of the party in
office
UCD:
Internal
fragmentation
PSOE
Tension between
economic and
health responsables
PSOE
Political
turbulences
Increasing claim
for reform
PP
Internal Tension
liberals/
reformers/
conservatives
Degree of
decentralization
Low High
Strong influence of
Catalan nationalist
party (CIU)
High
Strong regional
regulation activity
Catalan Law
High
Strong regional
innovation
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Resoults No reform
Health policy as a
autonomous policy
Universal right
Financing trough
taxes
Decentralization
Partial reform:
Abril report
Introduction of
personal payment
"Contrato-
programa"
Internal markets
Co-payment
More private
providers
Changing policies
2. A NEW INSTITUTIONAL SETTING: EL ESTADO DE LAS AUTONOMÍAS.
The so call “Estado de las Autonomías” is based on the idea of “Autonomy” as
regular form of relation between central Spanish government and the regions, but also as
“Autonomía” as a institutional setting for the regions to develop. The system implies very
important levels of self-government and decentralization. Main powers of autonomic
institutions (CCAA) and Central State are distributed into three different levels:
-Powers exclusive to the Autonomous Communities (AC): institutional
organization, territorial organization, urban policies, health, fishing in domestic waters,
education, culture, etc.
-Shared powers: the State determines the bases for these powers and the
Autonomous Communities then legislatively assume and execute them. I.e. development
and planning of economic activity, industry, agriculture, corporate credit institutions and
savings and loans (cajas de ahorros), etc.
-Powers expressly reserved for the central state: international relations, defence,
foreign commerce, the monetary system, etc.
The institutional model for Autonomous Communityi (A.C.) most extended is
composed of a Legislative Assembly that includes, a Governing Council that directs the
Administration, and a High Court of Justice integrated into the general organization of the
State Justice Administration. The Parliament selects from among its members the President
of the Community, who in turn names and presides over the Governing Council.
Bask Country and Navarra have significant differences with the rest of the Spanish
regions in terms of their relationship with central government. Both regions have the
maximum level of autonomy. The main difference is that both regions manage their own
fiscal system and fiscal administration.
From this institutional perspective, and after these first stages of development and
popular satisfaction for self-government recovery in regions like Galicia or Catalonia,
“Autonomía” face an increasing problem of public perception about levels of regional
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performance. A problem that it is a part of a major question: how to secure its institutional
consolidation?
There are few sources of information about levels of public satisfaction about
institutional performance. There are a lot of electoral surveys at the media, and also a lot of
public debate, but the real thing is an absence of enough information about what we call “El
Estado de las Autonomías”. Working from the perspective of Public Policy Analysis, we
note the work of a group of researchers from several Spanish universities (a team that it is
called ERA). First ERA report was published in 1997. Public perceptions about
“Autonomías” present the following main characteristics (ERA 1997):
The Autonomous Communities (AC) have became key actors in the Spanish
political life. One third of the Spanish GNP depends and relies on regional
decisions, regional politics and regional policies. AC are also key actor in terms of
management and implementation of public policies in Spain. Regional governments
and regional elites are relevant actors not only at regional levels. They also play a
very active role at Spanish and European levels. In other words, AC in Spain have
real power and real resources and they know how to use them. This does not mean
that public opinion must be unanimous about the level of success or failure of each
region or even the overall system.
The process of development and consolidation of the model of the Estado de las
Autonomías has not been an easy one. Conflicts and tensions between Spanish
governments, regional governments, local governments and Europe are frequent.
This type of conflicts can be considered a part, or even, a product of the system.
These conflicts have relevant effects on the ways public policies are formulated,
decided and implemented in Spain. These conflicts also have very significant
impacts on public perceptions about institutional performance and political
legitimacy of each of those levels of governance. These impacts are plural and have
several directions in each case, in each policy problem, in each moment of time and
in each region.
The Autonomous Communities are nowadays consolidated as institutions. There are
differences between regions, but in all of them, regional actors, elites, governments,
parliaments and administrations have become critical in terms of public policy
options and implementation, allocation of resources and economic, social and
political performance.
The Autonomous Communities have achieved a high degree of social acceptation
and legitimacy in terms of public perceptions. This very positive perception is also
true talking about the perceptions of social, economics or political elites. AC are
seen as good instruments for solving historical o identity problems, political
problems and policy problems. It is possible to talk about a general demand for even
more autonomy and decentralization in all regions. On the other side, there is also a
clear perception that El Estrada de lass Autonomies have created new problems and
challenges for the Spanish society.
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Autonomous Communities are also administration and organization. This is one of
the most controversial results of the decentralization process in Spain. On one side,
Autonomous administrations have provided better information and services for the
citizen. But on the other side, these regional administrations are seen or presented
frequently as symbols for all the problems of coordination, mismanagement,
increasing of public spending and inefficiency that the model has produced.
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3. REGIONAL HEALTH POLICIES IN SPAIN: A COMPARATIVE ANALYSIS
The Following tables 6-7 summarised two key elements of the new Spanish Health
system:
- Decentralization has provided a variety of administrative and organizative solutions.
- Competition for resources between regions has been a key variable in the expansion
of public health policies and also for the developing of new models of management
and administration inr order to:
o Maximimice efficiency and efficacy
o Improve institutional legitimacy.
Table 6 DESCENTRALIZATION OF HEALTH ADMINISTRATION IN SPAIN
(Source: author) MAME DIMENSION NATURE COMPETENCES
INSALUD National: Spain Public
Administration
Management of Social
Security
Design of health policies
and
management of Public
health services in regions
not decentralised
SAS Regional: Andalusia
Autonomous
administrative
organization
Health policy
Management of public
health services
SCS Regional: Canarias Autonomous
administrative
organization
Health policy
Management of public
health services
SCS Regional: Catalonia Public
Administration
Health policy
ICS Regional: Catalonia Autonomous
management
organization
Management of Public
health services
And
Social security
SERGAS Regional: Galicia Autonomous
administrative
organization
Health policy
Management of public
health services
OSASUNBIDEA Regional: Navarra Autonomous
administrative
organization
Health policy
Management of public
health services
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OSAKIDETZA Regional: Bask Country Private organization
under public control
Health policy
Management of public
health services
SVS Regional: Valencia Public
Administration
Health policy
Management of public
health services
Table 7 DISTRIBUTIONS OF RESOURCES BETWEEN REGIONS IN THE NEW
HEALTH FINNANCING MODEL (1998-2001)
Source: (Argenté y Alvarez 1998)
GENERAL
FUNDS %
ASSIGNED FUNDS
%
TOTAL
RESOURCES %
ANDALUCIA 18.07 18.04 18.07
CANARIAS 4.07 1.61 4.02
CATALUNYA 15.75 45.09 16.27
GALICIA 6.91 7.73 6.93
NAVARRA 1.34 1.42 1.35
BASK
COUNTRY
5.45 5.17 5.44
VALENCIA 10.23 4.85 10.13
Total Services
transferred
61.82 83.91 62.21
Rest of Spain
INSALUD
38.18 16.09 37.79
TOTAL NHS 100 100 100
Change and innovation have been intenser during the nineties. The descentralization
process, the increasing activity of regional health policy communities and the clear
perception between regional politicians about the importance of health policies for the
consolidation of regional governments have created the opportunity for it:
1. Regional governments have become key institutional actors in terms of legal control
of resources and political direction of health policies.
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2. Regional policy communities have developed new solutions and new policies for
regional politicians that needed them on order to prove (i) regional governments are
better managers than central governements, and (ii) health policies are improving
under regional direction. This new policies are very different from one region to
another, but there are some common basis:
a. Introduction of internal markets
b. Split between providers and buyers
c. Increasing spending in health policies, specially in terms of infrastructures
and human resources
d. Specif policies oriented to increase and improve the primary atention
system.
3. Health profesionals are playing a relevant role not only in terms of provision of
health services, but also in terms of management and political direction. It is not
unsual to find health profesionals managing hospitals, playing leading roles in
political parties or even as members of regional governments.
4. Private health systems and services are percieved by spanish people as a
complement of the public system. 80% of spanish health spending is public
spending and only 1.19% of GNP is devoted to private health.
The following table 8 and figure 1 show how the different health regional systems
are moving from the classic public, centralised model of public health provision and
financing towards other solutions and combinations with different degrees of itnroduction
of internal markets, split between providers an buyers or even the domminance of forms of
private provision as the final objective for the process of descentralziation and change in
some regions.
This process of change and innovation is not a homogeneous or pacific one. Many
times is nor easy to have reliable official data and many times is not easy to separate
information from propaganda, but two main characteristics seem to be present:
1. Try and experimentation seems to go faster for the provision question than for the
financing question
2. There is a common trend going from public provision solutions to private provision
solutions. There are differences in terms of intensity and speed but not in terms of
direction of change.
TABLE 8 CHARACTERISTICS OF REGIONAL HEALTH SYSTEMS IN SPAIN
(Source. Author)
REGION CHARACTERISTICS OF THE
SYSTEM
ANDALUSIA Public finance
Public provision
Central planning and systematic evaluation
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BASK COUNTRY Public finance
Evolution from public provision towards
New Public management
Split between providers and buyers
NAVARRA
Public finance
Public provision and New Public
Management
Transformation of traditional private
provider into public providers
Transformation of all workers in public
servants
GALICIA
Public finance
Public provision
New Public management
Evolution of public providers towards
private providers: foundations, MEDTEC
Creation of private providers
CATALUNYA
Public finance
Private providers
Introduction of internal markets
Split between planning and provision
VALENCIA
Public finance
Substitution of public providers Private
providers
"Renting" of public health services to
monopolistic private providers
Competition between public and private
providers
INSALUD
Public finance
Public provision
New Public Management
"Contrato Programa"
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Figure 1 HEALTH POLICIES IN SPAIN: A COMPARATION Source: author
PUBLIC Andalusia
FINANCE INSALUD
Galicia Euskadi Navarra
Catalonia
Valencia
PRIVATE
FINANCE
PRIVATE PUBLIC
PROVISION PROVISION
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As a concrete example of this variety of solutions between regional systems, the
following table 9 summarised how different regions organise the contracting of services
and how these different forms of contracting provide different combinations of public and
private management.
Table 9 MOST EXTENDED MODELS OF CONTRACTING IN SPANISH HEALTH
SYSTEM (Source: author, adapting Fernández 1996)
TYPE OF CONTRACT CARACTHERISTICS EXAMPLE
Contrato-programa -negotiation of objectives
for management and
financing
-results have impact on
managers continuity
INSALUD
Contrato-programa by
incentives
-negotiation of objectives
for management and
financing
-Incentives by results for
managers, professional,
workers..
SAS
Contrato-programa by
partial-risk
-Public finance
-negotiation of terms and
conditions for service,
labour, etc…
Contracting with Public
enterprises
Contracting out -agreement between parts Contracting of catering,
cleaning, etc.
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4. CONCLUSIONS
There have been three main trends all along the process of change in recent Spanish
health policies
1. A fast an extensive process of so called "health devolution" towards the regions
2. A transfer of increasing control of services to health professionals and managers,
but also more direct control by users and clients.
3. The search for new management, new resources for it and quality as an objective.
Table 10: HEALTH PUBLIC POLICY IN SPAIN: TRENDS OF CHANGE (source. Author)
BEFORE 1985 AFTER 1985
FINNANCE Public Public
Co-payment
PROVISION Public
National heath service
Public and contracting-out
Regional health services
Split between providers and
buyers
Internal markets
MANAGEMENT Public Introduction of private
management techniques
Private management
SERVICE PRIORITIES Specialized assistance
Quantity
Primary assistance
Quality
ROLE FOR PRIVATE
HEALTH
Marginal Complementary
MAIN ACTORS Professionals
Trade unions
Spanish politicians
Professionals
Regional politicians
Clients
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It is not easy to talk about results and even harder to evaluate them. Reliable data
are not enough. The decentralization process has been very Sometimes it is not easy to
separate real data and information from propaganda coming from regional governments.
But we can identify three main trends in terms of results
- Data of management and service quality are variable. There are
significant differences between regional systems, but also there are very
relevant differences inside each regional system. We can account for
relatively successful experiences of privatisation or introduction of internal
markets in Galicia, Catalonia or Euskadi, but also there are very relevant
failures of these solutions inside each of these regions. On the other side,
there are very successful experiences of totally public management in
Navarra or Andalusia.
- There are significant improving all over the country in terms of public
opinion and client's perception about quality and liability of public health
services in Spain (See table 10). This perception seems to be also true in
terms of quality measures of perceptions. In a much more recent study
(2000) made using a focus groups approach -distributed by- regions, there
was a general consensus that AC have contributed to improve the quality of
public services. Some data seem to be relevant referring to perceptions of
the people about the impact of decentralization for public health services:
i. There was a positive consensus in the groups from Andalusia,
Asturias, Canarias, Castilla-la Mancha, Extremadura, Navarra, Bask
Country; mainly regions where regions manage public health
services but they are doing so mainly through public provision
models.
ii. There was a negative consensus in the groups from Baleares,
Castilla-León, Aragón and specially Madrid; mainly regions where
Central State still manage public health services.
iii. There was no consensus about Health public services quality in
Catalonia, Valencia, Galicia; mainly regions where regions manage
public health services but they are doing so mainly through the
introductions of private management techniques, privatisations and
introductions of internal markets.
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Table 11 SATISFACTION WITH SPANISH HEALTH SYSTEM (Source: MSC 1994)
Positive
perception
Information
(1-7)
General
medicine
Specialised
medicine
Hospitals
Andalusia 44.9 3.5 5.2 4.7 5.2
Aragon 68.6 4.3 5.7 5.2 5.5
Canarias 53.0 3.2 5.3 4.7 5.4
Castilla-
León
66.1 4.4 5.7 5.3 5.7
Catalonia 55.8 3.4 5.0 4.8 5.2
Galicia 47.1 3.6 5.3 4.7 5.5
Navarra 67.9 4.1 5.7 5.1 5.7
Bask
Country
69.0 4.1 5.5 5.1 5.4
Valencia 51.7 3.7 5.3 4.6 5.2
Spain 58.1 3.8 5.4 4.9 5.3
- Competition for resources between regions and political competition inside
regions are key variables for explaining this process. Public health improve
in Spain cannot be explained without this dynamics of regional
competition. Also this institutional dimension is a key variable to explain
the increasing level of resources assigned to health problems and policies
and to explain the increasing public relevant of public heath questions for
public policy debate and political competition.
- The plurality of models and solutions adopted by the different regional
services, along with what we can call “public health devolution” has been
a key element for a massive extension of advanced health services and
care all over Spain.
- Also there is possible to talk about some kind of a so call “Spanish public
health market” with high degrees of competition for resources, results
and satisfaction of clients between different regional services and
models. In fact a new phenomena is taking place more frequently: Spanish
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people vote with their feet wherever they can. They move from one regional
public health system to another, especially if they live along regional
borders. Some examples of these phenomena are the transfer of public health
clients from Aragón to Catalonia and Navarra, from Santander to the Bask
Country, from Murcia to Andalusia. These phenomena even take a European
dimension: it is also frequent some transfer of public health clients from the
north of Portugal to Galicia.
- Also it is possible to identify in the Spanish public opinion an increasing
use of information coming from the different experiences and solutions
implemented in the regions. In fact, it is very common to use ideas, models
and solutions developed in other region as referents, demands or threats for
the health debate of another region. In other words, the people of one region
take advantage and knowledge from the experiences of other regions. This
knowledge comes from official results and data, but also -even mainly- from
other more informal sources like personal or experiences.
In other words. After decentralization of public health policies and services, Spanish
people know, care and demand much more. Results in terms of efficiency, efficacy and
quality are still open questions. Regional Governments say they are on the way, people are
not so confident.
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BIBLIOGRAPHY
ABÁSOLO ALESSÓN, IGNACIO. "Equidad y política autonómica de salud. Una aplicación del
principio del fair innings". Papeles de economia española. 76 (1998), 244-258
Alternativas de reforma para la sanidad pública. Madrid : Circulo de Empresarios, 1998.
10C/46 (61)
Análisis de los cambios de gestión pública sanitaria y de servicios sociales en Gran Bretaña
: tres documentos de estudio. València : Subsecretaria de Planificació i Relacions
Externes, 1998. 13B/17-17(35)(364)
Análisis económico de la sanidad. Barcelona : Departament de Sanitat i Seguretat Social,
1994. 2A/104 (614)
ARRATIBEL ARRONDO, JOSE ANTONIO. "El control financiero y de gestion del gasto
sanitario en Euskadi". Auditoria Publica. 19 (1999), 41-46
BAREA TEJEIRO, José ; GÓMEZ CIRIA, Antonio. El problema de la eficiencia en el sector
público en España: especial consideración de la sanidad. Madrid : Instituto de Estudios
Económicos, D. L. 1994. 2A/68 (351)
BAREA TEJEIRO, JOSE. "Estimacion del gasto sanitario autonomico: una propuesta
metodologica aplicada a Canarias". Hacienda publica española. 150-3 (1999), 37-66
BARR, Donald A. "Strategic management or environmental change : which determines
success in health care organizations?". Administration & Society, Sept. 1998, v. 30, nº 4,
p. 374-392. 13B/8-14 (338)
BERRANGER, Thibaut de. "Les compétences des régions en matière de santé dans les
quinze États membres de l'Union européenne : approche comparative pour contribuer à la
réflexion sur une éventuelle décentralisation du système de santé français". Revue de
Droit Sanitare et Social, avril-juin 1996, n.º 2, p. 249-273. 13A/12-10 (61)
BOHIGAS, Lluis. "El gasto sanitario en España en comparación con la Unión Europea".
Papeles de economia española. 76 (1998), 15-18
BORGONONI, Elio. "Gli indicatori di efficacia e di efficienza nella sanita". Rivista Trimestrale
di Scienza dell'Administrazione, 1996, nº 2, p. 181-190. 13A/19-12 (35)
BRUCE, ALLAN. "The politics of health charges in Britain: rhetoric and reality". Policy and
Politics. 27,4 (1999) 473-490
CABASES, JUAN M. "La financiacion sanitaria autonomica. Bases para una propuesta".
Papeles de economia española. 1998, (76): 67-77
CALONGE RAMIREZ, SAMUEL ; RODRIGUEZ MARTINEZ, MARISOL. "Consecuencias
distributivas y de equidad de las politicas de gasto y financiacion de la sanidad". Papeles
de economia española. 1998, (76): 259-272
COMUNIDAD EUROPEA. Comisión. Documento de trabajo de los servicios de la comisión :
Integración de las exigencias en materia de protección de la salud en las políticas
comunitarias (1996). [Luxemburgo] : [Oficina de Publicaciones Oficiales de las
Comunidades Europeas], 1998. 13B/3-13 (61)
COMUNIDAD EUROPEA. Comisión. Tercer informe de la Comisión al Consejo, al Parlamento
Europeo, al Comité Económico y Social y al Comité de las Regiones sobre la integración de
las exigencias en materia de protección de la salud en políticas comunitarias (1996).
Luxemburgo : Oficina de Publicaciones Oficiales de las Comunidades Europeas, 1998.
13B/3-17 (61)
ECHEBARRÍA, KOLDO ; SUBIRATS, JOAN. "Descentralización y coordinación de la sanidad
21
en el Estado autonómico". Papeles de economia española. 76 (1998), 78-93
ERIAS REY, Antonio ; CAINZOS, Juan J.F. ; PRADO DOMÍNGUEZ, Javier ; DOPICO
CASTRO,
Jesús. La eficiencia hospitalaria en Galicia : un análisis no-paramétrico. A Coruña :
Instituto de Estudios Económicos, Fundación Pedro Barrié de la Maza, 1998. 10B/210 (61)
FERNÁNDEZ DÍAZ, Jesús M. "Nuevas tendencias en los sistemas de salud europeos".
Boletín de estudios económicos, diciembre 1996, vol. LI, n.º 159, p. 423-434. 8A/194 (61)
FERNÁNDEZ SANTIAGO, José Manuel. "La descentralización en el Sistema Nacional de
Salud: una asignatura pendiente". Revista de Administración Sanitaria, jul.-sept. 1997,
vol. 1, n.º 3, p. 29-36. 13A/10-21
FRESNEDA FUENTES, María Silvia. "La reorientación en la gestión hospitalaria : estudios de
caso". Revista de Administración Sanitaria, 1998, v. 2, nº 7, p. 99-114. 13B/5-3 (61)
GIMENEZ MONTERO, ANTONIO. "La financiacion de la sanidad autonomica". Cuadernos de
informacion economica. 1997, (128 / 129): 67-76
GÓMEZ ASOREY, Carmen. "Tipologías de los sistemas sanitarios". Administración Sanitaria,
ene.-mar.1997,vol. 1, n.º 1, p. 45-58. 8C/158 (61)
GORRICHO VICIERS, José Andrés. "Proceso de cambio en el Instituto Catalán de la Salud".
Administración sanitaria, ene.-mar.1997, vol.1 n.º 1, p. 77-99. 8C/158 (61)
HANSON, Russell L. "Health-Care Reform, Managed Competition, and Subnational Politics".
Publius, 1994, v. 24, p. 49-68. 12C/44-17 (61)
HERRERO, Carmen ; PINTO, José L. Comparison and evaluation of states of health.
[Valencia] : IVIE, 1998. 16A/73-14 (61)
HERRERO, Carmen. An alternative theory of health care decision making. Valencia : IVIE,
1998. 16A/81-38 (61)
HITIRIS, T. "Health-care expenditure and integration in the countries of the European
Union". Applied Economics, Jan 1997, vol. 29, n.1. 16A/68-2 (61)
HSIAO, WILLIAM C. "¿Qué pueden aprender todos los paises de la experiencia de los
paises desarrollados en la financiacion de la atencion sanitaria?" Anthropos. 1991,
(118-119): 99-111
HUNTER,D.J. "Reforming United Kingdom's health care system". International Journal Of
Public Administration. 22,3-4 (1999), 425-460
JACOBZONE, STEPHANE. "Le systeme de sante francais aujourd'hui". Les Cahiers français.
292 (1999), 49-61
JORNADAS DE ECONOMIA DE LA SALUD (11ª. 1991.Alicante). El Sistema Nacional de
Salud
de los 90; Estrategia de Salud, Planificación y mercado. Valencia : Consellería de Sanitat i
Consum, 1992. 9B/264 (61)
LA MODERNIZACIÓN DE LA SANIDAD PÚBLICA EN EL MUNDO. Seminario Internacional
[1996. Madrid]. La modernización de la sanidad pública en el mundo. [S.l.]: Arthur
Andersen, 1997. 8B/151 (61)
LADENHEIM, Kala. "Health Policy Reform in America: Innovations from the States". Plubius,
1994, v. 24, n. 2, p.143-145. 12C/44-21 (61)
LÁZARO ALQUEZAR, Angelina. "La evolución económica en el sector sanitario en España".
Cuadernos aragoneses de economía, 1996 vol. 6, n. 1. 16A/68-4 (61)
LEARMONTH, MARK. "The national health service manager, engineer and father? A
deconstruction". Journal Of Management Studies. 36,7 (1999), 999-1012
LLUCH, Ernest. "Costos crecientes y éxitos sanitarios públicos". Administración sanitaria,
22
ene-mar. 1997, vol. 1, nº 1, p. 35-45. 8C/158 (61)
LOCOCK, LOUISE. " The changing nature of rationing in the uk national health service".
Public administration. 78,1 (2000), 91-110.
LOPEZ I CASASNOVAS, GUILLEM ; CASADO MARIN, DAVID. "La financiacion de la
sanidad
publica española: aspectos macroeconomicos e incidencia en la descentralizacion fiscal".
Presupuesto y gasto publico. 1996, (20): 123-152
LOPEZ I CASASNOVAS, GUILLEM ; IBERN REGAS, PERE. "Algunas consideraciones
basicas
para comprender las cifras de evolucion del gasto sanitario". Hacienda publica española.
1995, (134): 133-144
LOPEZ I CASASNOVAS, GUILLEM. "Acerca de la medicion y analisis de la eficiencia en las
organizaciones sanitarias publicas". Rae. Revista asturiana de economia. 1997, (8): 7-29.
13A/5-6 (61)
LOPEZ I CASASNOVAS, GUILLEM. "Apuntes para la reforma sanitaria de los noventa: las
formas organizativas son importantes". Informacion comercial española. Revista de
economia. 1992, (708-709): 63-77
LOPEZ I CASASNOVAS, GUILLEM. "Economia de la salud y gestion sanitaria: algunas
claves interpretativas". Presupuesto y gasto publico. 1993, (10): 5-22
LOPEZ I CASASNOVAS, GUILLEM. "Financiacion autonomica y gasto sanitario publico en
España". Papeles de economia española. 1998, (76): 2-14
LOPEZ I CASASNOVAS, GUILLEM. "Financiacion y gasto sanitario publico: evolucion
reciente". Economistas. 1998, 16 (77): 233-242
MARTÍN MARTÍN, JOSÉ JESÚS ; MANUEL KEENOY, ESTEBAN DE. "Reformas y cambios
organizativos en el Sistema Nacional de Salud español". Papeles de economia española. 76
(1998), 176-190
NONELL, ROSA ; BORRELL, JOAN-RAMÓN. "Mercado de medicamentos en España. Diseño
institucional de la regulación y de la provisión pública". Papeles de economia española. 76
(1998), 113-131.
NUÑEZ FEIJOO, ALBERTO. "El sistema de financiacion de la sanidad publica reflejada en el
presupuesto de 1998". Presupuesto y gasto publico. 1997-1998, (21): 123-136
RICO GÓMEZ, ANA. "La descentralización sanitaria en España: el camino recorrido y las
tareas pendientes". Papeles de economia española. 76 (1998), 49-66.
RICO GÓMEZ ANA. "Regional decentralization and Health care reform in Spain (1976-1996).
South European Society and Politics. Vol.1. número 3. 1996.
RIDAO, Manuel ; PEIRÓ, Salvador. Introducción a la evaluación económica. València :
Institut Valencià d'Estudis de Salut Pùblica, 1996. 13B/17-2 (33)
RIVERA CASTIÑEIRA, BERTA ; CURRAIS NUNES, LUIS C. "Factores determinantes de la
demanda de salud: evidencia empirica del gasto sanitario privado en Galicia". Revista
galega de economia. 1998, 7 (1): 221-242
RIVERS MOBLEY, L. ; BRADFORD, W. D. "Behavioral differences among hospitals : is it
ownership, or location?". Applied economics, Sept. 1997, vol. 29, n.º 9, p. 1125-1138.
13A/9-14 (61)
RIVERS MOBLEY, Lee ; MAGNUSSEN, Jon. "An international comparison of hospital
efficiency : does institucional environment matter?". Applied Economics, 1998, v. 30, nº
8, p. 1089-1100. 13B/5-30 (61)
ROMA RODRIGUEZ, JAUME. "La financiacion de los hospitales". Gestion hospitalaria. 1992,
23
(2): 53-60
ROMAY BECCARIA, José Manuel. "La sanidad española, presente y futuro". Administración
Sanitaria, ene.-mar. 1997, vol. 1, n.º 1, p. 27-33. 8C/158 (61)
RUIZ ALVAREZ, JOSE LUIS ; CASTET FERNANDEZ, M. LUISA ; CRESPO CASAS, JUAN
MANUEL. "Consideraciones sobre la reforma de la financiacion de la sanidad publica
española". Presupuesto y gasto publico. 1991, 3 (5): 173-196
TAYLOR, Malcom Gordon. Insuring National Health Case: The Canadian experience. Chapel
Hill and London : University of North Carolina Press, Cop.1990. 3B/253 (61)
TAYLOR-GOOBY, Peter. "The future of health care in six european countries: the views of
policy elites". International Journal of Health Services, 1996, vol. 26, n.º 2, p. 203-219.
13A/14 (61)
TOMAL, Annette. "The relationship between hospital, market and patient characteristics ".
Applied Economics, 1998, nº 30, p. 717-725. 13B/1-30 (61)
URBANOS GARRIDO, ROSA M. ; UTRILLA DE LA HOZ, ALFONSO. "Incidencia del
traspaso de
competencias sanitariasen los recursos autonómicos. Una simulación de escenarios
alternativos de financiación". Papeles de Economía Española. 83 (2000), 184-206
WALLER, Eddy. "A quantitative analysis of the health care resource allocations: the
private versus the public route in the United Kingdom". Applied Economics Letters, 1998,
v. 5, nº 9, p. 583-586. 13B/5-21 (61)
WILLIAMS, ALAN. "Medicina, economía, ética y el Servicio Nacional de Salud. ¿Un choque
de culturas?" Papeles de economia española. 76 (1998), 228-231
YUEN, P. P. "Managed care systems in the People´s Republic of China". International
Journal of Public Administration. 22,3-4 (1999), 499-524
i For a more detailed explanation of the institutional model of Galicia and its functioning,
see "O Sistema Politíco Galego. As Institucións" by Caamaño, Máiz, Rivera and Vilas,
Xerais, Vigo. 1994.