Proposals towards sustainability - Catalan case

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

Abstract

A group of experts was commissioned by the regional Catalan government to analyse the actual situation of the regional health sector. This initiative is embodied in the political process of negotiations between the regional governments in Spain and the central government, in order to achieve a new system of financing the decentralised regional public health services. Apart from intending to have a better public health system, this initiative is a way of trying to get more funds.

Purpose of health policy or idea

Main objectives are:

• The creation of the experts Committee is looking for expert advise on the actual situation of the system, and ways to improve it, basically in terms of financing, but also in terms of efficiency and quality, since the Committee considers that higher resources without reforms is not a good solution. The proposals of the Committee are broad, and include actions in the fields of access, organization (e.g. a decentralized territorial system with a per capita distribution of resources), distribution of costs among participants (e.g. possibility of changing the existing co-payment system, increasing the tax rate of tobacco taxes and the fiscal pressure in a more general way), ways of having higher resources for the public system (e.g. greater participation of regional governments in the central tax revenues, increases in the tax rates of certain taxes, the reduction of the contribution of Catalonia to the maintenance of the central government ), etc.
• From a political point of view, the government is probably seeking for legitimacy and acceptance of the reform process it is starting to implement.
• One of the main political objectives of the creation of the Committee of experts was to analyse and propose ways to improve the ever-insufficient resources problem. Within it, arguments and ways to increase the resources received from the central government is also a very important issue.

The instruments are going to be varied, depending on the measures finally adopted. They affect the regional organization of the public/private health system in Catalonia and the system of payment to providers, the labour conditions of some doctors and GPs of the public system, the fiscal relations between the central and regional governments, etc.

Depending on the measures finally implemented, various actors are going to be affected. For example, consumers/citizens through greater participation on the costs of the services, doctors and GP through changes in their labour conditions; patients if quality is finally improved; local administrations because of regional reorganization of the health services system, etc.

Main points

Main objectives

• The creation of the experts Committee is looking for expert advise on the actual situation of the system, and ways to improve it, basically in terms of financing, but also in terms of efficiency and quality, since the Committee considers that higher resources without reforms is not a good solution. The proposals of the Committee are broad, and include actions in the fields of access, organization, distribution of costs among participants, ways of having higher resources for the public system, etc.
• From a political point of view, the government is probably seeking for legitimacy and acceptance of the reform process it is starting to implement.
• One of the main political objectives of the creation of the Committee of experts was to analyse and propose ways to improve the ever-insufficient resources problem. Within it, arguments and ways to increase the resources received from the central government is also a very important issue.

Groups affected

Regional and central governments, Patients/citizens, Doctors, Providers and purchasers, pharmacy sector

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

Political and economic background

The change of the political parties in power in the regional government took place early in 2004, and short after there was also a change in the political party in power in the central government. Both are left-wing, and more close to each other than previously (before the elections in 2004). The central government has agreed to have a new system of financing of the regional health systems by 2006.

Change of 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 issues of the efficiency and quality levels of the public health system are not new, neither the issue of not having sufficient resources to finance the ever increasing health expenditure. However, the change of the political party governing the central level, by march 2004, has made for a re-initiation of conversations between the central government and the regional ones, about the financing of the regional health services.

Moreover, it seems that the system implemented by the previous central government political party in power, does not provide enough resources for the regional health services, and many regional authorities are demanding more resources and a reform of the system.

Within this context, some regional authorities have also done or are doing now an exercise to look for other alternatives to increase the efficiency, equity and sustainability of their health systems, in a similar way as the Catalan government has done.

The measures proposed by the Catalan experts committee are quite large and broad in scope. They provide a large array of measures for the government to choose. They are divided into two baskets: one related to an increase in funds; the others are related to increases in efficiency and quality.

Initiators of idea/main actors

• Regierung: The regional government was the one who commissioned the experts report or white paper. Therefore it is supportive on the issue, but it says it will not necessarily put into practice all the recommendations included in the white paper. It says it will look for an agreement with other political parties, and specially with the central government.

• Leistungserbringer

• Wissenschaft: Experts are in general in favour of the recommendations of the Committee, but some are more in favour of increasing health expenditure than others. Some differences also exist among them concerning specific proposals included in the white paper.

Approach of idea

The approach of the idea is described as:
renewed: This time the initiative is coming from the regional governments and is embodied in a new politicacal context.

Stakeholder positions

Some associations and professionals do consider that the proposals of the "Informe Vilardell" (which is the name commonly given to the report or white paper of the experts committee) are in general a good starting point for making reforms (e.g. the "Unió Catalana d'Hospitals" which is an association of Catalan hospitals; also "Médicos de Catalunya" which is a doctors labor union of Catalonia, or "CCOO" an important trade union).

However, they think that more work has to be done in terms of concretizing the general proposals to more specific ones, e.g. to define the benefits' basket of the public health system, which is important in order to know what amount of financing are we talking about.

Pharmacies do disagree with the proposals concerning drugs distribution: liberalizing the distribution and dispense of drugs and the possibility that the primary care centers and also the geriatric centers may be able to dispense drugs. Until now, pharmacies have the monopoly (there are around 3,000 pharmacies in Catalonia, for a population of around 7 million).

Actors and positions

Regierung
Regional government health minister	sehr unterstützend		stark dagegen
Regional government minister of finance	sehr unterstützend		stark dagegen
Leistungserbringer
GP and specialists, for the report in general	sehr unterstützend		stark dagegen
GP and specialists, for increasing labour hours	sehr unterstützend		stark dagegen
Wissenschaft
Academic experts	sehr unterstützend		stark dagegen
Health sector experts	sehr unterstützend		stark dagegen

Influences in policy making and legislation

It is expected that some of the proposals of the experts committee will be implemented in the near future but it is still not known which ones. However, some proposals, even though not necessarily in the same way as they have been proposed, are already being implemented. These are:

• Measures to increase the prominence of primary care within the whole public system, as a way to reduce the costs of specialized and hospital care and increasing the quality of services (through e.g. reducing waiting times).
• The increase in the ours of work of some doctors and physicians of  specialized and primary care, those that work only two hours a day. The government wants them to work more ours, so that more time will be devoted to the attention of the population. This measure is not well accepted by the providers affected.
• The creation in 2004, of a regional surcharge tax on fuel in Catalonia (as well as in other two regions, Galicia and Madrid).
• A new organization of health services within the region, tending to a more decentralized system, with a territorial base, that tries to give higher responsibilities to the different actors (public and private) involved in the health provision, purchasing and financing.

Legislative outcome

n/a

Actors and influence

Regierung
Regional government health minister	sehr groß		kein
Regional government minister of finance	sehr groß		kein
Leistungserbringer
GP and specialists, for the report in general	sehr groß		kein
GP and specialists, for increasing labour hours	sehr groß		kein
Wissenschaft
Academic experts	sehr groß		kein
Health sector experts	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

For the implementations of the broad array of measures proposed in the experts committee report, probably large agreements are going to be required with different actors, if the measures are to be successful. For example, with doctors and GPs in what concerns their labour conditions; with the central government in order to modify the actual system of financing of the regional health services, and probably also with other regional governments; with the regional agents involved in the provision, financing and organization of health services within the Catalan system (e.g. with Consortia and local governments) in order to reorganise the system in a territorial base; with the drug industry in what concerns the measures affecting reference pricing, generics and others related; etc. The government will also need to well justify to citizens and patients those reforms affecting the distribution of the burdens of the financing of the system (e.g. through greater co-payments). Of course the regional government may act without taking into account all this actors affected, but this would probably  not be the best way to achieve the objectives.

Expected outcome

It seems obvious that reforms have to be taken in the public health system, in terms of the distribution of resources between the central government and the regional ones, to tackle the problem of sustainability of the health system, but also reforms are needed to increase its efficiency, effectiveness, quality and equity. However, it is not an easy issue, and many political forces are working in this process. In fact, reforms of the health system that give higher prominence to the private health sector or introduce private management within the public sector are not well received by part of the society. Politicians are also reluctant to change the actual co-payments system, because it may have high political costs. Reorganizations within the sector are not easy, because they affect the acquired rights of different agents (e.g. doctors).

Even though all this difficulties, it is expected that some reforms will be implemented, and it seems that the political party in power is quite decided to do some of them. However, it is still early to assess their expected results, since it is still not known which ones are going to be implemented.

It is worth saying that even though if an agreement will come out between the central government and the regional ones to increase the financing of the regional health systems, an increase in the ratio public health expenditure/GDP will probably also mean in practice, that more effort will be demanded to consumers, either in the form of higher fiscal pressure and/or larger and broader co-payments.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

It is expected that quality will be improved, as well as its equity. However, it will depend on which and how different measures are implemented. In any case, it seems obvious that greater involvement in the costs of the system will be demanded to citizens and patients.

References

Sources of Information

• Grup de Treball per la racionalització i el finançament de la despesa sanitaria Document marc del grup de treball per a la racionalització i el finançament de la despesa sanitaria, Barcelona, 3rd February 2005.
• Various specialized newspapers and magazines press articles, and general newspapers articles.
• www.gencat.net/salut/depsan/units/sanitat/html/es/dir103/doc8702.html where you can find a resume of the proposals of the Committee.

Author/s and/or contributors to this survey

Martínez, Esther (CRES)

Empfohlene Zitierweise für diesen Online-Artikel:

Martínez, Esther (CRES). "Proposals towards sustainability - Catalan case". Health Policy Monitor, April 2005. Available at http://www.hpm.org/survey/es/b5/4