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Evaluating Catalan Integrated Health Care Schemes

Partner Institute: 
Centre de Recerca en Economia i Salut (CRES), Universitat Pompeu Fabra, Barcelona
Survey no: 
Gabriel Ferragut Ensenyat
Health Policy Issues: 
Organisation/Integration des Systems, Finanzierung
Reform formerly reported in: 
Catalonia: Integrated HC Pilot Project
Integrating health and social care
Debate on integrated care pilot projects
Current Process Stages
Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein nein nein nein ja nein
Featured in half-yearly report: G-politik in Industrieländern 10


Development of integrated health care organisations in Catalonia, particularly of population-based purchasing systems, is arousing notable interest both among academics and within health authorities. This report gives an account of an exhaustive evaluation of these organisations and the main conclusions of analysis thereon, in order to describe significant elements of the Catalan model, and to identify success factors and obstacles in these new organizations.

Purpose of health policy or idea

The purpose of this initiative is to provide an in-depth analysis of the coordination and integrated health care model developed in Catalonia. It also serves to distribute the conclusions, highlight weak points and catalogue future challenges to the implementation of new initiatives in this area.

Main points

Main objectives

Describe coordination model in the integrated health care

Analyse the different experiences of the existing integrated organisations in Catalonia, and evaluate their economic and health outcomes

Evaluate the impact of these organisations on the Catalan health care system

Analyse and spread good practices of the integrated organisations

Identify future areas of development to improve efficiency in the Integrated Health Care Organisations in Spain

Consider opportunities for the development of new initiatives

Type of incentives

Definition of a guide for the study of integrated organisations

Study of cases with multiple evidence sources

Groups affected

Providers, managers, Public purchaser, Professionals, patients


Characteristics of this policy

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

The unplanned nature of the origin of health system integration has created a diverse model in which organisations share characteristics, but notable differences exist. In particular, organisations differ in their form of inter-organisational relation (integration degree: virtual or real) and in the degree of development of some organisational elements that influence assistance coordination and efficiency.

In spite of these differences and the absence of a homogeneous model, the consolidation of these organisations may be considered an opportunity to develop innovations in the health system with potentially significant impact, both on efficiency and on user-perceived quality. Predictably, these innovations have been a major introduction due to organisations' need to adjust to coordinate (via disease management) those problems that are going to worsen in the coming years (in particular, attention to chronic diseases, comorbidity and dependency).

In addition, a major expansion is expected in the mechanisms that generate the incentives for ideal development of these organisations (as the introduction of a real capitation-based payment system, development of management tools and performance evaluation by government bodies of these organisations).   

Political and economic background

In recent years, providers, purchasers and health policy analysts have expressed an increasing interest in the development of integrated delivery systems (IDS). This has been translated into a notable consensus that they represent an innovative form of organisation capable of providing an answer to the emergent challenges in the environment of health (chronic diseases that need coordinated attention; alternative treatments to the conventional hospitalisation).

These organisations have appeared, most especially, in countries with many private providers and fragmented health care delivery systems, such as the United States, and in countries with social insurance systems (Germany, Austria) which have linked insurers and provider organisations with managed care.

18 Integrated Health Care Schemes in Catalonia

In Catalonia, these organisations have been progressively appearing inside a mainly state-run health care system (National Health System with diversification in ownership). The LOSC's (Health Care Organisation in Catalonia Act) approval made it possible to transfer management of the new primary care centres to external providers of the CIH (Catalonia Institute of Health), which in turn facilitated the horizontal and vertical integration that resulted in the Integrated Health Care Organisations. Currently, eighteen Integrated Health Care Organisations exist in the health care delivery system of Catalonia.

Complies with

Need to analyze Integrated Health Care Organisations in depth, to recognize weaknesses and strengths that should support the decisions on the generalization of these organizations.

Purpose and process analysis

Current Process Stages

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

Origins of health policy idea

The first Integrated Health Care Organisations in Catalonia appeared in the early 1990s, with the integration of the primary care centres that they were not managed by the ICS.

The original development of these entities was due more to the diversification policy in the provision of primary care in the framework of the LOSC, and less to a clear public policy of health system integration.

Leadership and economic incentives

Factors that stimulated the integration of organisations inside this legal framework, were basically economic (cost containment and scale economies), supported by the leadership exercised by certain hospitals' executives and by local administrations (in management consortia).

Consorci Hospitalari de Cataluya, the association of regional hospitals, entrusted to the Servicio de Estudios y Prospectivas de Salud (SEPPS) a thorough study of the model of integrated health care organisations in Catalonia, which has just been published and it has provided a wide view of these organisations.

Initiators of idea/main actors

  • Regierung: Nowadays, the integration between primary and hospital care has become one of the priorities of the Catalan government health policy. It has declared that there will be carried out structural changes to foment the integration of these two welfare levels.
  • Leistungserbringer
  • Patienten, Verbraucher
  • Andere: The association of regional hospitals has promoted the constitution of Integrated Health Care Organisations by publishing their experiences and advices.

Approach of idea

The approach of the idea is described as:

Innovation or pilot project

Local level - There has been a trend of expansion in assistance services to dependents (elderly nursing home residences, home assistance) and those in public health (health protection activities).
Pilot project - Pilot projects have been developed for the purchase of services across a population split into five geographical areas, which promotes supplier integration and improves the incentives to treat the problems in a more cost-effective manner.

Stakeholder positions

In the expansion of these organisations, there has never been a political leadership that has stimulated implementation, though neither has it restricted development. The main stakeholders involved in the development of these organisations have been the managers of the hospitals, due to an economic interest, and the local governments, which are keen to retain welfare services in their territory. Consorci Hospitalari de Catalunya has also promoted the constitution of Integrated Health Care Organisations by publishing their experiences developed in this area.

Recently, the main health authorities of the Catalan government have announced that the development of these organisations is one of their highest priorities.

Actors and positions

Description of actors and their positions
Catalan Ministry of Healthsehr unterstützendsehr unterstützend stark dagegen
CatSalut (Catalan Health Service)sehr unterstützendunterstützend stark dagegen
Primary Care Centerssehr unterstützendunterstützend stark dagegen
Hospitalssehr unterstützendsehr unterstützend stark dagegen
ICS (Catalan Institute of Health)sehr unterstützendneutral stark dagegen
Patienten, Verbraucher
Patientssehr unterstützendunterstützend stark dagegen
Consorci Hospitalari de Catalunyasehr unterstützendsehr unterstützend stark dagegen

Influences in policy making and legislation

The development surrounding the introduction of these organisations has not supposed the promulgation of a specific law that regulates the area. But it is possible that soon may be carried out structural changes that need legislative modifications, if the manifestations of the health authorities are fulfilled.

Legislative outcome


Actors and influence

Description of actors and their influence

Catalan Ministry of Healthsehr großgroß kein
CatSalut (Catalan Health Service)sehr großgroß kein
Primary Care Centerssehr großneutral kein
Hospitalssehr großsehr groß kein
ICS (Catalan Institute of Health)sehr großneutral kein
Patienten, Verbraucher
Patientssehr großgering kein
Consorci Hospitalari de Catalunyasehr großgroß kein
Catalan Ministry of Health, Consorci Hospitalari de CatalunyaHospitalsPatientsPrimary Care CentersCatSalut (Catalan Health Service)ICS (Catalan Institute of Health)

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Despite having an origin defined by a few common reasons that jointly determined the process of integration (vertical integration, from the hospital level to a previous level in service provision), the Catalan IDS organisations implemented the process in different ways which has resulted in different models.

The most prominent differences concern the extent of integration (number of units that provide the service), the reference population, and the judicial forms under which they have been constituted (either management consortia with single-ownership or organisations with different ownerships that establish links between primary care and hospitable attention).

The problems during implementation were partly due to the non-existence of health authorities planning, and also to the maintenance of a purchasing system for line of services. These problems reduce the incentives for coordination with other suppliers and between assistance levels, which assure gains in efficiency and equity in access.

Monitoring and evaluation

Mechanisms of evaluation have not been developed by the sanitary authorities responsible for the provision of health services. Monitoring and internal evaluation by these organisations and pilot initiatives has turned out to be insufficient from the performance approach. The information produced thus far has focused on the intermediate outputs of the different units and has not been related to health outcomes.

In reference to the capitation-based payment experience (2001-2005) that has included three Integrated Health Care Organisations, wider mechanisms have been developed to evaluate results, but up to now have provided only preliminary and partial results, that have contributed to some recommendations for generalisation.

The external evaluation published by Consorci Hospitalari Catalunya about the Health Care Integrated Organisations has been the most exhaustive evaluation of this area. It consists of case-by-case analyses of the application of a guide for the study of these organisations. The approach of this guide consists of an analysis of the internal organisational elements, the environment determinants, the process development of coordination and the performance degree of these organisations of agreement to their final aims. This study provides a detailed analysis of the strengths and weaknesses of a sample of these organisations, and in addition, has generated a general vision of the Catalan health care integration model.

Review mechanisms

Halbzeitevaluation, Abschlussevaluation (extern)

Dimensions of evaluation

Struktur, Ergebnis, Prozess

Expected outcome

The expected effects of the implementation of these organisations consists, in general, of an increase in the global efficiency of the system by means of, firstly, horizontal and vertical integration of health care levels and, secondly, units which facilitate coordination between levels. The first creates economies of scope and scale, as well as a decrease in transaction costs and unnecessary services. Vertical integration supposes an improvement in coordination and control along with continuous assistance, and providing that the incentives are suitable, favours the resolution in the more cost-effectiveness level.

Impact of this policy

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

The expected effects from the implementation of these organisations are minor compared to what should be expected. Some aspects necessary for the proper development of these organisations have not been applied during the process of implementation. In addition, some deficits exist in the planning (population of reference) and in the development of mechanisms for coordination between units and with external suppliers. The tools of performance evaluation are very limited, since they place greater emphasis on the incentives for efficiency inside a given level of care, and less on coordination and cooperation between care levels.

The capitation payment pilot project constitutes an exception that has addressed some of these questions, and has consistently promoted incentives for effective assistance coordination. There remains, however, a need to modify some elements of the design of the model of purchase, such as: assignment with a needs-based (and risk-adjusted) capitation funding system (not for effective cost) and to eliminate the contracts of purchase for assistance line.

The exhaustive analysis of these organisations and of the integrated health care model developed in Catalonia reveals a definite need to intensify the development of elements that stimulate cooperation and integration, without which the desired results will not be obtained. Improvement and subsequent generalisation of the capitation funding system is the solution to the mentioned lacks.


Sources of Information

  • Vázquez Navarrete, ML and Vargas Lorenzo,I. Organizaciones Sanitarias Integradas. Un estudio de casos. Barcelona.Consorci Hospitalari de Catalunya, 2007.
  • Ibern Regás, P. Integración asistencial: fundamentos, experiencias y vías de avance. Barcelona. Elsevier-Masson, 2006.
  • Consorci Hospitalari de Catalunya:
  • Various specialized newspaper articles. Available at:
  • Various specialized newspaper articles. Available at:

Reform formerly reported in

Catalonia: Integrated HC Pilot Project
Process Stages: Umsetzung
Integrating health and social care
Process Stages: Umsetzung
Debate on integrated care pilot projects
Process Stages: Pilotprojekt

Author/s and/or contributors to this survey

Gabriel Ferragut Ensenyat

Empfohlene Zitierweise für diesen Online-Artikel:

Gabriel Ferragut Ensenyat. "Evaluating Catalan Integrated Health Care Schemes". Health Policy Monitor, October 2007. Available at