«The management of health systems in the EU Member States - The role of local and regional authorities The study was written by Progress Consulting ...»
SLOVENIA Main characteristics of the Slovene health care system ►Mostly centralised although executed through local branches, with some responsibilities held by local authorities (municipalities) at primary care level ►Providing nearly (99%) universal coverage through a mandatory health insurance system ►Mainly public financing of health care – contributions from the national insurance system and, to a much lesser extent, general taxation at a national and municipal level ►Mixed service provision – public and private Structure of the system The central level, through several bodies, is responsible for administrative and regulatory functions, policy, planning (including those of health personnel), establishing priorities and budgetary issues. The Ministry of Health prepares legislation and monitors its implementation, deals with health financing, public health and medicine supply and market; it also manages public health care institutions at the secondary and tertiary level. The Health Insurance Institute – HIIS, is a public independent body supervised by the government in charge of administering the social health insurance regulated by national legislation and on which the national health system has been based since 1992 with the adoption of the Health Care and Health Insurance Act.
Public health facilities at the secondary and tertiary care levels are owned by the government. Local governments are responsible for planning and maintaining the primary care network, including pharmacies. Municipalities own public primary health care centres and grant concessions for private health care providers at primary care level, where concessions allow providers to access the market of services to be reimbursed by compulsory and complementary insurance schemes. Overall, the role of the local government is still limited and in practice their planning functions are mostly theoretical. Besides receiving funding from the central level, municipalities also raise their own financial resources through local taxation. Since long-term care is also provided within the scope of primary care, in the forms of community nursing care and home health care, local authorities also contribute financially to these services.
Delivery of services Service providers are mainly public but the number of private providers is increasing, especially at primary care level. Primary care, including diagnostic services, is delivered through public primary health care centres, for emergency care and general practice, health stations, and private general practitioners. At secondary care level, services are provided by hospitals (or polyclinics) and private facilities. Almost all hospitals are public. Secondary care is accessible through referral of the personal physician (gate-keeping system). Patients can freely choose their physician. Emergency care services are integrated within the primary and secondary care structures.
Services are purchased by the HIIS and health insurance companies. Usually negotiations occur, ending up in general and special agreements between the HIIS and the providers (individual professionals or institutions such as hospitals and primary care centres). Compulsory health insurance provides access to a package of benefits; services not included in the package require co-payments (from 5% to 75% depending on the service) that are covered by complementary or voluntary insurance.
Pharmacies were all owned by municipalities in 1992, while in 2005 out of the 273 existing pharmacies, 84 were private.
Finance and health care expenditure The system is mainly funded through public sources but there is a significant share of private funding (27.8% in 2006) through co-payments and complementary insurance. Complementary insurance is taken up by the majority of those contributing to compulsory insurance (98%, equivalent to the coverage of 85% of the whole population) and is solely for covering co-payments; since 2005, the same premium has applied to all individuals, regardless of age and company, according to a ‘risk equalisation scheme’ put in place by the Ministry of Health (all funds collected by the voluntary insurance companies are firstly pooled together and then re-distributed according to the scheme). Most of the public expenditure (67.1% in 2006) is out of the public insurance system;
contributions to the public insurance systems are from earnings. Another public source contributing to some 5.2% of total health expenditure in 2006 is general taxation, at the national (from income tax, corporate tax, VAT and excise tax) and municipal level; this is mostly to cover capital investments in publicly owned structures, in particular, for local authorities, for the provision and maintenance of health care centres, health stations and public pharmacies.
Albreht T. et al. (2009), Health Systems in Transition. Slovenia: Health system review, European Observatory on Health Systems and Policies.
SPAIN Main characteristics of the Spanish health care system ►Highly decentralised, with an important role played by regional authorities (Autonomous Communities) ►Providing universal coverage mostly free of charge at the point of service ►Mainly public financing of health care – out of general taxation, including regional taxes ►Mixed service provision – mainly public and only to a lesser extent private Structure of the system Since 2002, responsibilities for health care have been devolved to the 17 Autonomous Communities. The national Ministry of Health and Social Policy is responsible for the financing of the system.
Additionally, it oversees the pharmaceutical sector, guarantees proper functioning of the system, issues basic health and social care legislation, defines minimum benefits packages and quality standards, monitors, and provides general coordination; the coordination body is the Inter-territorial Council of the national health system, chaired by the national Minister and including the 17 regional ministers of health; the Council may only produce recommendations.
Policy, regulatory, planning, and organisational responsibilities for the regional health systems are with regional health ministries (Consejería de Salud). Within the basic benefits package agreed at the national level, regional health ministries may define packages tailored to regional preferences; they also define the system of health care areas and basic health zones. A regional health service (Servicio Regional de Salud) performs as service provider, usually through two organisations, one for primary and one for secondary care (ambulatory and hospitals), although integrated structures delivering both types of care are being piloted across regions. The regional health service may also purchase services from third parties, contracting nonpublic providers by means of several ‘legal formulae’ or arrangements. The regional health service assumes responsibility for operational planning, service network management and coordination of health care provision.
Historically, local authorities have been involved in the management of health care; their participation in health governance is through local councils where monitoring and consultation tasks are undertaken. Additionally, hospital participation committees, with representatives of municipalities and local consumer associations, allow for contributions to hospital management.
However, overall, the role of local authorities is limited, although some large municipalities may still have the resources to carry out important health initiatives. In general, regional authorities administer almost 90% of the resources allocated to health; a small amount (more than 1%) is also directly administered by municipalities, the rest being spent at the central level.
Some 95% of the population is covered by a general social insurance regime that entitles access to the public health system; in addition, there are three special regimes for civil servants; finally, there are private voluntary schemes, increasingly carried out and covering, on average across regions, some 13% of the population. Voluntary insurance schemes enable access to services for which there are long waiting times in the public system, or that are not included in the benefits package, such as adult dental care.
Delivery of services Delivery of services occurs within a structured territorial framework based on a system of health areas and zones (health care ‘map’) that often do not correspond to administrative boundaries. Each health care area (161 in 2010) has a catchment population between 200,000 and 250,000 people and comprises several basic health zones, which are the smallest units of the organisational structure for primary health care delivery. Primary care is delivered through a public network of Health Care Centres. In rural areas with a low population density there are local medical offices. In each health zone, with a catchment population varying between 5,000 and 25,000 inhabitants, a primary care team (PCT) has a gate-keeper function.
Access to specialised care requires a referral from a general practitioner, with the exception of emergencies that are handled through 24-hour primary health care emergency centres or hospital emergency wards. Specialised care is provided in Specialist Care Centres (centros de especialidades) and hospitals in the form of outpatient and in-patient care. Each health area has at least one general hospital. In 2008, there were some 804 hospitals, with around 40% of them belonging to the public health system, the others being private. Hospital management is by the Autonomous Communities or through other arrangements such as public-private partnerships.19 In Catalonia, the Regional Health Service (CatSalud) is the purchaser of services through the Catalan Hospital Network of Public Utilisation (XHUP). This Network includes both public and private providers such as ‘consortiums and municipal associations, public corporations, private foundations, workers’ mutualities, religious charities, private firms and professional associations/cooperatives’ (Garcìa-Armesto S. et al., 2010). These providers constitute associative-based entities (Entitats de Base Associativa - EBAs), i.e. groups of primary care professionals constituted as enterprises with their own legal status, that, on the basis of contracts finalised with the regional health services, manage basic health zones, becoming, in practice the Primary Care Team of reference.
The pharmaceutical sector is regulated by the central government but regions are represented in the National Commission for the Rational Use of Pharmaceuticals, under the Inter-territorial Council of the national health system, deciding on reimbursement. Prescription and dispensing is the responsibility of regional health departments within the respective ministries.
Medicines can only be dispensed in pharmacies; these are private profit-making businesses that may be owned only by pharmacists and whose licence, once won through public tender, becomes a commodity. There is a 40% co-payment contribution by citizens on the retail price, with exemptions applied to some categories (pensioners and chronically ill patients).
HOPE online country profile – Spain: latest information refer to 2007
Finance and health care expenditure There is no earmarked budget for health; regions cover health expenditure out of their general budgets that, in turn, are determined by existing financing mechanisms from the central to the regional governments. On average, public health accounts for 30% of the regions’ total budget.
The share of public health expenditure is about 71%; private financing within total health expenditure is 28.8% (2007), sourced almost entirely from upfront payments by citizens for medicines (40% co-payment).
Public health care expenditure is almost exclusively funded (some 94%) through general taxation. Revenues from taxes are totally or partially assigned to regions; regions have direct control over taxes on gifts and inheritances, properties and property transfers, and gambling taxes; while they receive around 35% of personal income taxes and VAT, and 40% of taxes on consumption of hydrocarbon-based products, tobacco, alcoholic beverages and electricity.
The regional ministries allocate the funding, in most of the cases to the regional health service, as the main provider, with whom global annual budgets are negotiated. In turn, the regional service negotiates global annual contracts with providers of primary care, specialised and hospital care. Private providers may also be contracted, and the regional health service may act as a purchaser rather than a provider.
- National Health System of Spain, 2010. Ministry of Health and Social Policy
- Garcìa-Armesto S. et al. (2010), Health Systems in Transition, Vol. 12 No.4, Spain Health System Review, European Observatory on Health Systems and Policies
- Guillén Rodríguez A.M. et al. (2010), Annual National Report 2010 – Pensions, Health and Long-term Care: Spain. ASISP: Analytical support on the Socio-Economic Impact of Social Protection Reforms.