Decentralization of Health Services Competencies

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

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Abstract

Leading to a formal piece of legislation the Spanish government adopted a policy to establish a public purchasing system with integrated and coordinated health care providers based on the covered population in some specific areas of Catalonia. Then to transform individual contracts buying services to several providers for capitation based contracts with integrated health care organizations. It led to a piece of legislation in May 2002.

Purpose of health policy or idea

• This Act is now (march 2003) on Parliamentary debate (draft act), previous to its approval and enactment. It is a central government piece of legislation, within the context of decentralization of health management responsibilities to 12 regional authorities (autonomous governments), in 2002. Previously, 5 autonomous communities already had decentralized their health services. Now health services are decentralized to all regions. Financing of regional health services was also modified to be included within the general regional governments' system of finance. 
• Its main objectives, as stated by the text of the law, are to coordinate and homogenize the services provided by the public health system, among all regions, basically in terms of treatments and products offered, improve quality and guarantee equal access to health services across regions. To do so, the law includes among others, a list of services which the regional health authorities will be obliged to provide, which can be complemented by regional governments; a Fund financed by the central government to pay for health treatment of individuals across regions.
• Coordination of the national health system will be done mainly by an already existing organization, the "National Health System Inter-territorial Council" (NHSIC from now on), in which all regional health authorities are present, as well as the central government health authority. It is expected that this NHSIC will be given larger powers (which means more regional government participation) on health policy issues, but there is some fear that they will reduced basically to public health issues; the central government will still keep large control on issues that affect the national health system.

Specific objectives of the law are:

1. to guarantee patients a second health expert opinion;
2. to provide equal access to each individual all across regions, by means of a special fund that will cover the costs of moving patients from one region to another;
3. to create a "catalogue" of treatments and services included in the national health service, which can be increased by each regional health authority;
4. to increase patients' information on waiting times and the guarantee of an homogeneous maximum waiting time all across regions;
5. to create a national homogeneous information system on each individual;
6. to regulate health professionals career.

 

• Regional governments are mainly affected by this Act; many of them are reluctant because the Law is seen as a possible way of centralization of health responsibilities (e.g. certification of reference health centres; career regulation); regional governments also want more guarantees from the central government on the financing of new services which are to be included and the regional governments will have to provide.

 


 

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Political and economic background

• As already said, this Law is in part the result of a process of health management and responsibilities decentralization, from the central government to regional tiers, which started in Spain more or less around the beginning of the 1980s. For long time only 5 autonomous communities had health responsibilities, and it was expected that the rest would also have them, after a process of decentralization of powers from the central to regional governments.
• The Spanish right wing central government has approved and enacted a series of  regional "coordinating" and "homogenization" acts in different fields (e.g. education, fiscal stability) since it came into power. Hence, this "health homogenisation law" could be included within this package, together with the fact of health management and financing decentralization to all autonomous communities.
• This Law is so broad that in some sense may become a way of modifying the "Ley General de Sanidad" (Health Law, 1988), e.g. in the configuration of boards or institutions for biomedical investigation, .High Inspection; which will be probably regulated by the central government.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The initiative has come from the central government, and its unique political party also has the majority in the Parliament. This Act can be included within the series of laws that this government has already approved and enacted (e.g. in education and fiscal stability), all of them having in common the objective of homogenization across regions, and some kind of limitation of regional governments' powers.

Stakeholder positions

• Opposition to this law has come mainly by the autonomous governments and by the political parties in the opposition (some of them are dominant in regional governments). Opposition has been mainly in two fronts: 1) reduction of autonomous communities' powers (e.g. in what concerns the services provided and the way of providing them, in terms of techniques and procedures); 2) insufficient financing to achieve the objectives included in the law, especially in what concerns the provision of new services and procedures.
• Since the coverage of the law is quite ambitious (coordination and homogenization across all Spain), and health management and financing is within the regional governments responsibilities, the central government has looked for some kind of consensus with the autonomous communities and the main political parties, although none of them directly participated in the elaboration of the Act drafts. It is also worth saying that the political party in the central government is also the majority one in the Spanish Parliament, so that no other party is needed for the Act to be passed in the Parliament. The consensus looked for has been pursued before the Act enters the Parliamentary debate, through conversations between the government and the political parties in the opposition and the autonomous communities. This consensus seems to be achieved, at least in terms of the global of the law, although political parties are still presenting their amendments to the Act project which is debated in the Parliament. However, due to this effort on "consensus", it is foreseeable that the Parliament will approve it in short time.
• "Consensus" has been achieved by means of the central government including in the law text, some of the items demanded by the political parties in the opposition and autonomous communities, e.g. to give a larger role to the NHSIC in policy decisions, and to create a mechanism to study the financing possibilities when dealing with the enlargement of health services provision.
• Other actors that have been consulted are medical and drug associations, trade unions and others. Generally they have been in favour of the contents of the Law, especially in what concerns the objective of guarantying to citizens a given package of services all across regions. Each actor requested the inclusion of some items affecting their group, which are explained in what follows.

Influences in policy making and legislation

• The original proposal made by the central government was modified with the inclusion of some of the items requested by main political parties and by some other relevant actors. Their inclusion was of main importance to achieve some kind of approval by those parties. They are as follows:
•  - Autonomous governments in general, and most political parties wanted a more clear definition of which was going to be the central government contribution to the financing of the services included in the law. These services, whose provision will be compulsory to the regional health authorities, will be somehow larger than the already provided, e.g. dental care, and mental health).
• - the socialist party (the second greater one at the Spanish level), together with other political parties, have succeeded in including that any new service guaranteed to citizens should previously pass an economic evaluation and be debated in terms of how is it to be financed, with greater financial implication of the central government, not to be only of communities fiscal responsibility.
• - Trade unions demanded an enlargement of the coverage of national health services, like dental services and mental health care, as well as large consensus with autonomous communities and greater decision powers of the NHSIC, which have partly been incorporated in the Act Project (this last issue was also strongly demanded by regional health authorities).        
• Medical and other health professionals associations asked for a unified regulation of their professions, to be applied across all regions, as well as professional improvements and more implication in the debate and implementation of the Act. The first item cited is to be developed with the Act. 
• The Federation of Associations for the Defense of the Public Health System  (FADSP) considers the Law a good idea, although it comes too late; it also thinks that more financing to the public health system will be basic for it success . It also emphasises the need for greater role of the autonomous communities on health policy decisions, and the need for a National Health Plan, not only for given pathologies.

 

Adoption and implementation

• Apart from was has already been explained, citizens are supposed to be positively affected by the Act, basically in terms of the services provided:
• 1. A maximum waiting time for health services reception will be established.
• 2. There will be a catalogue of minimum services which the regional health authorities will have to provide.
• Those services will probably be larger that the existing ones, mostly in: dental care, mental services, services for the handicapped:
• Guarantee of a second health professional opinion for the patient.

However, most of the services within the catalogue are still to be specified; that will be done after the Act will be approved, by the central government and the NHSIC.

Part of the law is also very generic, so that its development by the central government will be easy to accommodate to it; this can also create problems with regional health authorities, which are the ones that will have to implement it.

 

 

Expected outcome

All the relevant aspects have already been stated. Most problems will probably come from the financing of the services provided, and the possible confrontation between the central and regional governments, in terms of health responsibilities and powers on health policy. Some differences may come out between the regions that already had powers on health policy and the ones that have them since 2002.

References

Empfohlene Zitierweise für diesen Online-Artikel:

. "Decentralization of Health Services Competencies". Health Policy Monitor, 20030506. Available at http://www.hpm.org/survey/es/b1/5