Health Policy 119 (2015) 100–106
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The effects of the financial crisis and austerity measures on the Spanish health care system: A qualitative analysis of health professionals’ perceptions in the region of Valencia Francisco Cervero-Liceras, Martin McKee, Helena Legido-Quigley ∗ London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom
a r t i c l e
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Article history: Received 22 July 2014 Received in revised form 29 October 2014 Accepted 5 November 2014 Keywords: Austerity measures Financial crisis Spain Qualitative study
a b s t r a c t The recent financial crisis has seen severe austerity measures imposed on the Spanish health care system. However, the impacts are not yet well documented. We describe the findings from a qualitative study that explored health care professionals’ perception of the effects of austerity measures in the Spanish Autonomous Community of Valencia. A total of 21 semi-structured interviews were conducted with health professionals, recorded and fully transcribed. We coded all interviews using an inductive approach, drawing on techniques used in the constant comparative method. Health professionals reported increases in mental health conditions and malnutrition linked to a loss of income from employment and cuts to social support services. Health care professionals perceived that the quality of health care had become worse and health outcomes had deteriorated as a result of austerity measures. Interviewees also suggested that increased copayments meant that a growing number of patients could not afford necessary medication. While a few supported reforms and policies, such as the increase in copayments for pharmaceuticals, most opposed the privatization of health care facilities, and the newly introduced Royal Decree-law 16/2012, particularly the exclusion of non-residents from the health care system. The prevailing perception is that austerity measures are having negative effects on the quality of the health care system and population health. In light of this evidence there is an urgent need to evaluate the austerity measures recently introduced and to consider alternatives such as the derogation of the Royal Decree-law 16/2012. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction In 2008 the European financial crisis spread to Spain. Despite a strong economy, with a low level of national debt, it experienced a banking crisis when a housing bubble, fueled by low interest rates, collapsed [1]. The consequent
∗ Corresponding author. Tel.: +44 (0) 20 7636 8636; fax: +44 (0) 20 7927 2701. E-mail addresses: [email protected] (F. Cervero-Liceras), [email protected] (M. McKee), [email protected] (H. Legido-Quigley). http://dx.doi.org/10.1016/j.healthpol.2014.11.003 0168-8510/© 2014 Elsevier Ireland Ltd. All rights reserved.
loss of confidence by international lenders led to a rise in interest rates and the government spent massive sums to bail out the banks. There was a severe loss of public confidence, exacerbated by revelations of political corruption. In 2009 the country experienced a double dip recession and, unable to borrow on the international markets, was forced to obtain a bail-out from the European Financial Stability Facility. The Spanish economy continues to face a grim outlook in 2014 with a meager net growth of 0.6%, and a total public debt that has now risen to 95% of GDP [2]. The rescue package was coupled with a series of fiscal consolidation policies, also known as austerity measures.
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These measures consisted of a series of cuts to the welfare system, including education, health and social services, a reduction in public sector salaries, new labor laws and increases in taxes [3–5]. Their stated purpose was to regain the trust of financial markets and private investors and to reduce bond yields. However, the reduction in demand has meant that GDP per capita has been falling steadily while the debt ratio has doubled [6]. Budget cuts designed, ostensibly, to eliminate the government deficit have arguably made the situation worse. The crisis has had dramatic consequences for Spanish families, with unemployment peaking at a rate of 26% (5,977,500 persons) in 2013, and with 22% of families living under the poverty line [7]. Austerity measures applied to the health care sector included a new Royal Decree-law 16/2012, which fundamentally changed the healthcare system from where entitlement was based on residence to one where it was based on contributions [8]. This has meant that whole groups of the Spanish population are excluded from preventive and primary and secondary care services coverage. The budget allocation for health and social services was reduced by 13.7% in 2012 and 16.2% in 2013, with some regions imposing additional budget cuts. The rate of copayment for pharmaceuticals increased and the previous exemption of pensioners was revoked. Those with higher incomes will pay 10% of the cost of their medicines, with the rest paying D 8, D 18, or D 60 monthly payments, depending on their pension income [3]. With the new increases in copayments, those earning less than D 18.000 per year have to pay 40% of the medication and those earning more than D 18.000 have to pay 50% of the total cost [3]. The health workforce was cut by 28,500 in less than two years [9] and Autonomous Communities began privatizing services. The health care system in the Valencian Autonomous Community was not spared budget cuts, with politicians invoking the sustainability of the health care system as a justification. The Valencian region was well known as the setting for the so called “Alzira scheme”, the first example in Spain of private companies assuming responsibility for healthcare services within a geographical area. This scheme consists of ten-year term period contracts between the Valencian Government and a joint venture to construct hospitals and manage both the clinical and non-clinical facilities. However, despite efforts to promote it widely, growing concerns about this model have led social movements to oppose attempts to adopt similar reforms, and protestors in Madrid managed to stop the privatization process. Most of the studies published discussing the effects of the financial crisis and austerity measures on health and health systems in Spain have been descriptive in nature. The limited available evidence suggests that suicides have gone up in some areas of Spain [10,11] with increases being associated with rises in unemployment. Major depression has risen by nearly 20 percentage points, attributable to a considerable extent to job loss, mortgage foreclosure and evictions [12] and poverty has increased dramatically among children, with nearly 30% being at risk of poverty or social exclusion [8,13]. This study fills a gap in the literature by analyzing the impact of the financial crisis and the policies adopted to mitigate its effects on the Spanish
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Table 1 Participants’ characteristics. Male Profession: Nurses Doctors Province: Valencia Alicante Area: Urban Rurala Type of care: Primary careb Secondary carec Workplace: Public centers Privatized centers Private sector Total
Female
Total
2 9
3 7
5 16
7 4
7 3
14 7
4 6
7 6
13 12
4 7
4 6
8 13
7 4 7
6 2 2
13 6 7
11
10
21
Note: When totals exceed 21 this is because the interviewees worked in more than one setting. a Rural Includes Hospitals in middle sized towns covering villages. This included two private hospitals. b Primary care also includes occupational health and one interviewee from the ambulance service. c Secondary care includes specialist consultants working at public polyclinics or their own private clinics and an interviewee working in long term care.
health system by means of a study of the Valencian region. It examines the effects of those reforms and austerity measures through the experiences of healthcare professionals. 2. Materials and methods Participants were selected using convenience and snowball sampling. A total of 21 semi-structured face to face interviews with healthcare professionals were conducted during May and June of 2013. Five nurses and sixteen doctors, with regular contact with patients from a wide range of specialties were interviewed. They worked at different centers in the public, privatized and private sector, both in urban and rural areas. The questionnaire covered the perceived current and long term effects of the financial crisis and austerity measures on population health and the healthcare system; the ethical dilemmas faced by the professionals, their perception about policy development; the impact of specific policies; and their proposed solutions to the crisis. The questionnaire was designed using an iterative process to include new topics as they arose during the interviews. Table 1 describes participants’ characteristics. The study received ethical approval from the Ethics Committee of the London School of Hygiene and Tropical Medicine. The interviews were recorded and transcribed in full. All participants were presented with an information sheet, and consent was obtained for the interviews to be audiorecorded. All interview materials were stored securely to assure confidentiality. Once transcribed, the data were analyzed and coded using inductive approach and thematic analysis supported with QSR NVivo 10 software. Each excerpt also includes the number of the interview so that extracts from the same individual can be linked.
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We coded all interviews using an inductive approach, drawing on techniques from the constant comparative method, such as line by line analysis of early interviews, naming each line and segment of data, the use of subsequent interviews to test preliminary assumptions, and the comparison of codes and cases across our data set and other literature [14,15]. Excerpts and codes were discussed line among the authors to explore the themes that were emerging. In order to ascertain saturation, we identified deviant cases and explored them further. We have organized this paper around seven main themes following from the analysis of the data: perception of the impact of the financial crisis and austerity measures on population health; the effects of austerity measures on the healthcare workforce and quality of care; perception of the introduction of copayments and their impact; views on the Royal Decree and its impact; views on models of provision and the privatization process; governance of the health care system; and the solutions proposed by health care professionals.
3. Results 3.1. Perception of the impact of the financial crisis and austerity measures in population health Participants were asked whether they had experienced a change in the type and incidence of diagnoses since the outset of the financial crisis. Health care professionals reported examples of patients whose nutrition was severely affected. It was reported that families were being pushed into buying less food or cheaper options “now the main problem (of the Spanish population) is what and when to eat, it is not being able to pay the bills, it is to be able to feed your children (I09)”. As one doctor warned: Soon cases of malnourishment and even undernourishment will be noticeable. I won’t compare them to statistics of developing nations, but for a developed country they will be striking (I04). Several interviewees suggested that less food intake led to hunger and malnutrition while substitution of nutritious foods for cheaper and less healthy foods could lead to obesity, and difficulty adhering to diets and nonpharmacological treatments. Regarding mental health conditions, most healthcare professionals perceived an increase in levels of anxiety and depression due to the economic crisis. These were seen as having negative repercussions for existing physical ailments as well as giving rise to psychosomatic problems. An increase in the number of suicides was reported. However, while some mental health professionals perceived increased rates of anxiety, few reported an increased incidence in major psychiatric disorders. As one interviewee worried by this occurrence explained: No, we don’t think that the number of patients with mental illnesses has increased; nonetheless we were able to perceive, at some point, that there is an adaptive reaction of the citizens with anxiety and depression symptoms due to the socioeconomic context. [. . .] A process of great
suffering and stress is generated, which is more a worrying than a mental illness (I01). Health care professionals noted how some patients were suffering health problems due to the obligation to assume greater responsibility of caring for their dependents. This was exacerbated by cuts to social care budgets and insufficient household resources to pay caregivers or care homes. A nurse working in primary care of a rural health center explained: There were people in a home care that had to leave. In fact here there was a patient that was taken out of home care. He had an 80 year old brother, and he was almost 90. He had a tracheostomy, urethral catheter [. . .] The brother couldn’t pay for the home care bills anymore. He took him home and in less than two weeks he was taken to hospital (I11).
3.2. The effects of austerity measures on the healthcare workforce and quality of care The healthcare workforce was affected by cuts in the number and working hours of staff, exacerbated by forced retirements. Some participants expressed their anger about wage cuts and not having enough staff to cover those on leave: The crisis has justified everything! Everything aimed towards reducing expenses, from stationery to not substituting colleagues during long leaves, loss of employment, people that leave and their positions are not covered. . . everything everything! (I13). There were also reports of stricter control of sick leave, reduced funds for research and inappropriate use of doctors in training (residents) “many times you take decisions that you shouldn’t and do things that you shouldn’t be doing as a resident [. . .] they just don’t open new positions (for doctors) despite the growing demand (I20)”. The increased workload, further pressure at work, a decrease in the number of referrals allowed, and reductions in equipment, were all believed to have had an impact on the quality of health care “There is an increase of workload for the remaining staff, which decreases the quality of care (I13).” Several interviewees also complained about the increase in waiting times and overcrowding of hospitals and primary care centers as well as emergency services. The two next quotes are examples of the many reports: The quality of the assistance is decreasing, completely, the waiting times for interventions and consultations are growing. [. . .] Hospitals and primary health centers are overcrowded (I14). I-Do you think it is really affecting the quality of care? I20-Without any doubt, it doesn’t seem logical to me that a 83 year old granny is waiting up to 3 days in an Emergency Room because there are no beds available [. . .]. Now they are putting chairs in between ER beds because there are no beds, to avoid hiring more nurses, not to hire more doctors, not to hire more porters (I20).
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Interviewees also mentioned how it was becoming more difficult to transfer patients to more appropriate facilities when specialist care was needed. The cuts have also meant a decrease in the number of beds and out-of-hours availability of emergency care in rural settings, as a doctor explained:
The majority of health care professionals, who were against the introduction of copayments, shared stories of patients being unable to pay for medication. For example a surgeon recalled the story of a patient not taking his antirejection medication because he could not afford to pay for it, and later dying of a related complication:
By decreasing the numbers of hours that staff work, healthcare coverage has decreased [. . .] this center at 9pm is already closed, it really affects the user [. . .] The rural population is the most affected (I10).
R-So, when a patient comes and tells you that he can’t afford the drugs, you pick the drugs he’s got and prescribe the minimum, so at least he stops using the more expensive and less useful pills. . . I-And that affects their health? R-Yes, he was a cardiac transplant patient, he stopped taking his medication and died. I don’t know if he died due to an infection or varicella. I-And he stopped taking it because of this issue (copayment)? R-Yes, he stopped taking it because he didn’t have enough money (I20).
Most interviewees reported negative effects on the quality of care provided, which they linked to worse health outcomes. The above mentioned closure of emergency services and ambulances was believed to increase the risk of avoidable deaths in the rural population: There were cuts in the ambulance services, hence, ambulance arrival time has become longer from 5 to 15 minutes, and this translates into a risk of avoidable deaths (I09). A pediatrician complained about the difficulty of providing basic care due to the scarcity of basic sanitary pads for women and even restrictions of drinking water for patients: For example during deliveries [. . .] the lack of specific things like having to ask for sanitary napkins for the bleed postpartum and you have to get the things with a dropper (one by one). They don’t want (to give it). Plus a sick person being there and not having water provided for example. . . I think it shouldn’t be this way (I15). A few professionals reported that quality of care had not been compromised and may actually have improved due to some of the changes introduced or to the resilience of healthcare professionals. However, most suggested that, in the long run, the cuts would have a negative impact on patients: There is pressure, but I see it more from an administrative point of view. I think the service, as a health service, hasn’t been affected, but it will end up being affected. They are going to start to restrict procedures. . . (I04). Health care professionals working in the private sector reported a decrease in the number of patients and insured people, and cuts in staff and available resources. As a doctor recalled “there are less people with private insurance and therefore we have fewer patients in the private sector, moreover the companies (insurance) have a tighter control on expenditure (I02)”.
3.3. Perception on the introduction of copayments and their impact Some interviewees supported the introduction of small fees both for pharmaceuticals and for access to services, as a way of “educating” the patient or to raise awareness about the cost of care “I think that they (the users) are gaining more consciousness of the use of the public (health) system (I06)”. One interviewee argued that these measures needed to be coupled with the appropriate education.
Another health care professional working in the emergency services recalled an ethical dilemma arising from an inability to provide free medication when needed. In this account she provides the example of a mother unable to afford medication to reduce her child’s fever: For example, a dilemma occurs when a person comes to emergency services, and you know, she says she hasn’t got the 2 euros for the Apiretal, not even the Dalsi (both are common analgesics) for her son. You feel like giving her the Apiretal and the Dalsi for the baby. You know the mother doesn’t have the income to buy it and the child has fever. It is not the child’s fault. . . (I14).
3.4. The views and impact of the Royal Decree There were mixed opinions about the new Royal Decree, Law 16/2012, introduced in 2012. The Royal Decree has meant that whole groups of the Spanish population (mainly undocumented migrants) are excluded from preventive and primary and secondary care services coverage. Around a third of professionals supported the implementation of the decree, especially the way that it targeted the nonSpanish population, both migrant and tourists. However, the majority of interviewees were against it and defended universal health coverage as a basic principle of the Spanish health system, a feature all interviewees reported being proud of. The following was a nurse’s opinion: Terrible! As a nurse, terrible! Because for me care is universal, I don’t pay attention to race, color, nationalities. . . Because the Spanish health care system, which I am very proud of, was of universal coverage. It means, whoever comes to this country, has his health assured, at least his health care. It (the new decree) seems terrible! (I12). Around half the interviewees had doubts about whether the Royal Decree was being implemented, either because managers would not impose it or because health care professionals were finding ways to disobey it and provide the same care as before. However, there was also a sense that this would not last very long:
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P-There is an Argentinian family that has all the correct documents to receive healthcare. But one of the sons is over 18 and he doesn’t have them. He is a psychotic with a schizophrenic disorder and is impaired, so he has no healthcare coverage. I-And how did you proceed? P-Looking for subterfuges in a thousand ways, and there is still around two years for a legal process, an administrative process, to obtain the coverage. Meanwhile it is discussed, it is enquired, it’s done, but for now it is given (the care) [. . .] but I know that at any point it will be removed (the right for coverage) (I13).
3.5. Comparisons of different models of health care provision and views on privatization During interviews, health care professionals talked about their experiences and perceptions of the effects of the financial crisis in the public and privatized centers, in some cases comparing both systems. Some interviewees working for the private sector believed that public sector professionals worked fewer hours and had no supervision or insufficient incentives to improve productivity. A general perception of ineffective management persisted, especially regarding leadership and use of resources: Everything is underused [. . .] There are specialties where the operating rooms are not used sufficiently [. . .] And then there are some mistakes with appointments. . . like suddenly the patient is appointed for surgery but has no consent signed or hasn´ıt been seen by the anesthetist (I18). A few suggested that improvements were taking place in these areas since the introduction of austerity measures. For example a nurse reported “right now the administrative system has changed, including modification of drug prescription dispensing. . . well done, I think it is logical and fair (I08)”. Some interviewees highlighted the difficulty in comparing public and privatized facilities due to the different level of resources, institutional arrangements and the difficulty in disentangling the effects of the financial crisis. Overall, only a few professionals had a positive perception of privatized centers, reporting that there was better management, less wastage and the quality of the care was similar to that provided in public centers. Some interviewees expressed negative opinions of private hospitals in Valencia. Complaints included early discharges, risk selection, and cream-skimming of patients to increase profits. It was argued that restriction in the number of referrals and early discharges could be damaging to patients’ health. The story of a patient whose leg had to be amputated due to not being transferred on time was shared by one participant: A patient arrived after a motorbike accident. And he happened to be from Valencia, but because it’s better for the hospital if he stays in this hospital, they didn’t refer him (to the appropriate hospital)[. . .] They did it (the amputation) because he had been here retained for three days [. . .] Then they send the patient outside (to another hospital), in a desperate manner, because they had already messed up.
Imagine, of course horrible things are happening. Horrible! They don’t want to refer anybody to another hospital, and this is not ethical, not ethical at all (I21). Overall, most healthcare professionals were against further privatization. They argued that this model pursued profits and prioritized cost saving at the expense of adequate patient care “everything is an excuse so they can keep earning money, the less you spend, the less (patients) you admit, the better doctor you are, those are the only criteria, the patients are the least important (I19)”. 3.6. Governance issues: a major concern The perception of corruption and mismanagement was often mentioned in interviews and at all levels of the health care system. At facility level, interviewees reported drugs being taken home regularly and heard cases of expensive equipment being stolen from public hospitals. Professionals working in the private sector reported knowing of cases of corruption within their centers. There were particular concerns about the potential for corruption in private concessions delivering public services, with frequent calls for tight control of these arrangements during interviews. At the system level, politicians, policy makers and top level management were blamed for not having the knowledge, experience and information needed to take decisions that would improve the health care system. Moreover, most interviewees perceived a lack of planning and claimed that decisions were made precipitously. Healthcare professionals complained of being excluded from the design and implementation of healthcare policies. Participants highlighted a lack of consensus in the introduction of healthcare reforms and a low level of engagement with associations and citizens. In addition, they expressed concerns regarding a lack of transparency and communication of the new policies. As a result, health care reforms were believed “to be doomed to failure”. In the following quote a doctor describes how decisions are normally made by those who do not know about the topic: So the clinical consequences are not taken into account because (the decisions) are not taken by those who know about the topic. Of course! (I05). 3.7. Solutions proposed by health care professionals Often healthcare professionals felt puzzled and found it very hard to propose a specific solution to the new challenges. Privatization, the Royal Decree and user charges were considered, by a few, as possible solutions. Conversely, the majority saw that steps required for a solution were to stop privatization or abolish user charges and the royal decree. The provision of education for the population on the appropriate use of health services was often advocated as a possible alternative to reduced health care expenditure. The solutions that were most often mentioned by health care professionals included improved governance and management; the need for optimization of resource use; decreased wastage; the use of evidence-based guidelines; better staff management; improved productivity;
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performance measurement and more auditing. As a healthcare professional mentioned: I believe there must be a continuous optimization of health systems. There must be an optimization and the ability to assume errors through non punitive audits with the goal of keeping improving (I01). There was a demand for accountability, responsibility and increased transparency concerning the activities and decisions made by all parties involved, specifically healthcare professionals, managers and politicians. As a doctor demanding transparency explained: Transparency, there is very little. Transparency is the “quid” of the issue. Well, transparency does not exist. But it does not exist at a hospital level and I don’t believe either at political level or national level. . . (I17). Finally, their participation in decision making was seen as essential for success although there was an overwhelming view that so far they had not been consulted throughout the process of agenda setting and policy making.
4. Discussion The results of this paper shed light upon health care professionals’ perceptions of how the financial crisis and austerity measures are affecting the functioning of the Spanish health care system in the Valencian Autonomous Community. As perceived by healthcare professionals, austerity measures are having an adverse impact on the quality of healthcare provided and health outcomes of their patients. They foresee more negative effects. The health of the Spanish population was perceived as being compromised by the financial crisis, mainly with increases in mental illness and reported cases of malnutrition. Austerity measures, particularly in social services, had also led to increases in anxiety. In the health care sector, views were divided about certain measures, such as introduction of copayments, the implementation of the new Royal Decree or more sanctions on sick leave. But despite this disagreement, the majority recognized the negative health consequences of these measures and most reported being willing to take measures to circumvent them. Several professionals believed that the public sector was making strides in improving efficiency, and a few others believed that the privatized model was a possible solution. However, the majority of interviewees viewed this privatization process with concern, due to the profit maximizing behavior of private companies associated with impaired quality and worse working conditions for healthcare professionals. Some professionals inside the privatized model described severe cuts in referrals and early discharges that harmed patients. This may be a result of the current economic incentives derived from provider payment mechanisms. The system of governance has failed in the eyes of healthcare professionals, with serious issues ranging from corruption inside and outside the health system, lack of participation, transparency, and accountability. Alarmingly, the results confirm that all five of the policy responses
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to the financial crisis identified by Mladovsky et al. (2012) as undermining health system goals have been adopted in the Spanish health system [16]. They include attrition of health workers by wage cuts, forced retirement and worsening working conditions. There were also suggestions that waiting lists for essential services were increasing; some services, such as emergency care, were reported as no longer being accessible in rural areas; user charges have been applied to essential drugs; and population coverage has been substantially reduced by the new decree. The new Royal Decree is a complete turnaround of the vision of universal coverage and free services at the point of delivery, and experts have suggested that it might be in conflict with the Spanish Constitution [8,10]. It establishes a divide between populations entitled to public healthcare and those who will be forced to pay for their care even when accessing public providers. By deliberately targeting groups such as immigrants and people that have not had an opportunity to contribute to social security, it establishes a new paradigm of social justice in the Spanish care health system. This exclusion of part of the population is most surprising in an era when the WHO is promoting a strategy of universal health coverage globally. The findings of this study highlight the adverse effects of copayments in the Spanish population. There were reports from patients not being able to afford medication for their children and of patients not taking their medication after surgery, in one case viewed as contributing to their death. There is substantial evidence of the negative impact of user charges in healthcare, showing how even small fees have a negative effect on efficiency, equity, health outcomes and cost containment [17,18]. Furthermore, recent evidence shows a deterioration in health outcomes in hypertensive patients when user charges are increased [19]. These consistent findings with others conducted in Spain [20,21], which resonate with the experiences of the health care professionals interviewed in this study, suggest that the removal of user charges would facilitate better health outcomes. Many interviewees perceive a political agenda behind the process of privatization, consistent with previous research on this matter [22]. The potential for corruption in Spanish healthcare is not only perceived nationally but at an international level [23]. Recent evidence by the Valencian authorities corroborates the concerns of some healthcare professionals about the externalization of health services leading to a greater expenditure than those provided by the public sector, amounting to a staggering D 16.7 million in Valencia [24]. The added value of this study lies in its ability to capture perceptions that challenge official narratives. It also provides accounts of what is happening in areas where there are gaps in government data and provides a finely textured picture of what is happening on the ground. A limitation of this study is that it only covers one Autonomous Community in Spain, and therefore it is not representative of what is happening elsewhere. Since the management of health care is devolved to each region, further research is needed in other regions of Spain to have a whole picture of the current situation. The Valencian region is atypical in several ways. The health care cuts have been introduced
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at a slower pace than in other Autonomous Communities such as Catalunya and Madrid; it is a stronghold of the Conservative Party (Partido Popular); it has large numbers of tourists, resident British pensioners, and immigrants working in agriculture; as well as being the first to introduce the Alzira model of public-private partnerships which has been highly contested in the rest of Spain. One of the strengths of this study is that, to the best of our knowledge, it is one of the first studies conducted ascertaining the views of health care professionals in Spain, and the first exploring their views in the region of Valencia. 5. Conclusion The results of this study already highlight growing problems with affordability of medicines and access to healthcare, providing sufficient justification to lower copayments and increasing exemptions. Further research is needed to evaluate current policies, with an emphasis on user charges and the effects of the Royal Decree; an assessment of systems of governance; a review of decision making processes in respect of resource allocation and use; and a consideration of the effects of economic incentives on provider payment mechanisms in privatized providers. The proposed health care reforms were highly contested, with opposition from many professionals who expressed serious concerns about poor governance and widespread corruption. There is an urgent need to establish a policy making process that is transparent and based on the best available evidence and sound evaluations so that the Spanish population and health care professionals regain trust in their institutions and so that the proposed reforms do not further damage the most vulnerable in the population. Conflict of interests No conflicts of interest. Funding No funding was received in order to conduct this study. Acknowledgements To all healthcare professionals that helped making this research possible. References [1] Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu S, Stuckler D, et al. Financial crisis, austerity, and health in Europe. Lancet 2013;381(9874):1323–31.
[2] INE. Encuesta de Población Activa (EPA) Segundo trimestre de 2013 [Population survey, second quarter of 2013]. Madrid: Instituto nacionald e Estadistica; 2013. [3] Legido-Quigley H, Otero L, la Parra D, Alvarez-Dardet C, MartinMoreno JM, McKee M. Will austerity cuts dismantle the Spanish healthcare system? British Medical Journal 2013;346:pf2363. [4] Gene-Badia J, Gallo P, Hernandez-Quevedo C, Garcia-Armesto S. Spanish health care cuts: penny wise and pound foolish? Health Policy 2012;106(1):23–8. [5] Gallo P, Gene-Badia J. Cuts drive health system reforms in Spain. Health Policy 2013;113(1–2):1–7. [6] International Monetary Fund. World economic outlook, October 2012. Coping with high debt and sluggish growth; 2012. Available from: http://www.imf.org/external/pubs/ft/weo/2012/02/pdf/ text.pdf [cited 17.12.12]. [7] Foesa, Caritas. Exclusión y Desarrollo Social: Madrid 2012. [8] Legido-Quigley H, Urdaneta E, Gonzalez A, La Parra D, Muntaner C, Alvarez-Dardet C, et al. Erosion of universal health coverage in Spain. Lancet 2013;382(9909):1977. [9] El Pais. La plantilla de la sanidad pública cae a cifras récord: ˜ 2014. Available from: http://sociedad. 28.500 menos en dos anos; elpais.com/sociedad/2014/07/01/actualidad/1404215444 467226. html [cited 03.07.14]. [10] Legido-Quigley H, Otero L, Parra D, Alvarez-Dardet C, Martin-Moreno JM, McKee M. Will austerity cuts dismantle the Spanish healthcare system? British Medical Journal 2013;346:2363. [11] Lopez Bernal JA, Gasparrini A, Artundo CM, McKee M. The effect of the late 2000s financial crisis on suicides in Spain: an interrupted timeseries analysis. European Journal of Public Health 2013;23(5):732–6. [12] Gili M, Roca M, Basu S, McKee M, Stuckler D. The mental health risks of economic crisis in Spain: evidence from primary care centres, 2006 and 2010. European Journal of Public Health 2013;23(1):103–8. ˜ 2012. In: Prensa ND, edi[13] INE. Encuesta de Condiciones de Vida Ano tor. Datos provisionales [Conditions of life survey, 2012, provisional data]. Madrid: Instituto Nacional de Estadistica; 2012. [14] Strauss AL. Qualitative analysis for social scientists. Cambridge: Cambridge University Press; 1987. [15] Charmaz K. Constructing grounded theory: a practical guide through qualitative analysis. London: Sage; 2006. [16] Mladovsky P, Srivastava D, Cylus J, Karanikolos M, Evetovits TS, Thomson S, et al. Health policy responses to the financial crisis in Europe: policy summary 5. World Health Organization on Behalf of the European Observatory on Health Systems and Policies; 2012. [17] Newhouse J, Insurance Experiment Group. Free for all? Lessons from the RAND health insurance experiment. Harvard University Press; 1993. [18] Thomson S, Foubister T, Mossialos E. Can user charges make health care more efficient? British Medical Journal 2010;341:c3759. [19] Maimaris W, Paty J, Perel P, Legido-Quigley H, Balabanova D, Nieuwlaat R, et al. The influence of health systems on hypertension awareness, treatment, and control: a systematic literature review. PLOS Medicine 2013;10(7):e1001490. [20] Benach J, Tarafa G, Muntaner C. El copago sanitario y la desigualdad: ciencia y política [The health copay and inequality: science and policy]. Gaceta Sanitaria 2012;26(1):80–2. [21] La Federación de Asociaciones para la Defensa de la Sanidad Pública. Las repercusiones del copago sobre la utilización de medicamentos por los pensionistas [the repercusions of copayment in health care utilization among pensioners: Madrid]; 2013. [22] Acerete B, Sttaford A, Stapleton P. Spanish healthcare public private partnerships: the ‘Alzira model’. Critical Perspectives on Accounting 2011;22:533–49. [23] Daley S. Small-town Mayor’s millions as exhibit a on graft in Spain, in New York Times; 2013. New York. [24] Sindicatura de Comptes. Resonancias magnéticas: Una oportunidad de ahorro Auditoria Operativa de Conciertos Sanitarios, Valencia; 2013.
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The effects of the financial crisis and austerity measures on the Spanish health care system: A qualitative analysis of health professionals’ perceptions in the region of Valencia Francisco Cervero-Liceras, Martin McKee, Helena Legido-Quigley ∗ London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom
a r t i c l e
i n f o
Article history: Received 22 July 2014 Received in revised form 29 October 2014 Accepted 5 November 2014 Keywords: Austerity measures Financial crisis Spain Qualitative study
a b s t r a c t The recent financial crisis has seen severe austerity measures imposed on the Spanish health care system. However, the impacts are not yet well documented. We describe the findings from a qualitative study that explored health care professionals’ perception of the effects of austerity measures in the Spanish Autonomous Community of Valencia. A total of 21 semi-structured interviews were conducted with health professionals, recorded and fully transcribed. We coded all interviews using an inductive approach, drawing on techniques used in the constant comparative method. Health professionals reported increases in mental health conditions and malnutrition linked to a loss of income from employment and cuts to social support services. Health care professionals perceived that the quality of health care had become worse and health outcomes had deteriorated as a result of austerity measures. Interviewees also suggested that increased copayments meant that a growing number of patients could not afford necessary medication. While a few supported reforms and policies, such as the increase in copayments for pharmaceuticals, most opposed the privatization of health care facilities, and the newly introduced Royal Decree-law 16/2012, particularly the exclusion of non-residents from the health care system. The prevailing perception is that austerity measures are having negative effects on the quality of the health care system and population health. In light of this evidence there is an urgent need to evaluate the austerity measures recently introduced and to consider alternatives such as the derogation of the Royal Decree-law 16/2012. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction In 2008 the European financial crisis spread to Spain. Despite a strong economy, with a low level of national debt, it experienced a banking crisis when a housing bubble, fueled by low interest rates, collapsed [1]. The consequent
∗ Corresponding author. Tel.: +44 (0) 20 7636 8636; fax: +44 (0) 20 7927 2701. E-mail addresses: [email protected] (F. Cervero-Liceras), [email protected] (M. McKee), [email protected] (H. Legido-Quigley). http://dx.doi.org/10.1016/j.healthpol.2014.11.003 0168-8510/© 2014 Elsevier Ireland Ltd. All rights reserved.
loss of confidence by international lenders led to a rise in interest rates and the government spent massive sums to bail out the banks. There was a severe loss of public confidence, exacerbated by revelations of political corruption. In 2009 the country experienced a double dip recession and, unable to borrow on the international markets, was forced to obtain a bail-out from the European Financial Stability Facility. The Spanish economy continues to face a grim outlook in 2014 with a meager net growth of 0.6%, and a total public debt that has now risen to 95% of GDP [2]. The rescue package was coupled with a series of fiscal consolidation policies, also known as austerity measures.
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These measures consisted of a series of cuts to the welfare system, including education, health and social services, a reduction in public sector salaries, new labor laws and increases in taxes [3–5]. Their stated purpose was to regain the trust of financial markets and private investors and to reduce bond yields. However, the reduction in demand has meant that GDP per capita has been falling steadily while the debt ratio has doubled [6]. Budget cuts designed, ostensibly, to eliminate the government deficit have arguably made the situation worse. The crisis has had dramatic consequences for Spanish families, with unemployment peaking at a rate of 26% (5,977,500 persons) in 2013, and with 22% of families living under the poverty line [7]. Austerity measures applied to the health care sector included a new Royal Decree-law 16/2012, which fundamentally changed the healthcare system from where entitlement was based on residence to one where it was based on contributions [8]. This has meant that whole groups of the Spanish population are excluded from preventive and primary and secondary care services coverage. The budget allocation for health and social services was reduced by 13.7% in 2012 and 16.2% in 2013, with some regions imposing additional budget cuts. The rate of copayment for pharmaceuticals increased and the previous exemption of pensioners was revoked. Those with higher incomes will pay 10% of the cost of their medicines, with the rest paying D 8, D 18, or D 60 monthly payments, depending on their pension income [3]. With the new increases in copayments, those earning less than D 18.000 per year have to pay 40% of the medication and those earning more than D 18.000 have to pay 50% of the total cost [3]. The health workforce was cut by 28,500 in less than two years [9] and Autonomous Communities began privatizing services. The health care system in the Valencian Autonomous Community was not spared budget cuts, with politicians invoking the sustainability of the health care system as a justification. The Valencian region was well known as the setting for the so called “Alzira scheme”, the first example in Spain of private companies assuming responsibility for healthcare services within a geographical area. This scheme consists of ten-year term period contracts between the Valencian Government and a joint venture to construct hospitals and manage both the clinical and non-clinical facilities. However, despite efforts to promote it widely, growing concerns about this model have led social movements to oppose attempts to adopt similar reforms, and protestors in Madrid managed to stop the privatization process. Most of the studies published discussing the effects of the financial crisis and austerity measures on health and health systems in Spain have been descriptive in nature. The limited available evidence suggests that suicides have gone up in some areas of Spain [10,11] with increases being associated with rises in unemployment. Major depression has risen by nearly 20 percentage points, attributable to a considerable extent to job loss, mortgage foreclosure and evictions [12] and poverty has increased dramatically among children, with nearly 30% being at risk of poverty or social exclusion [8,13]. This study fills a gap in the literature by analyzing the impact of the financial crisis and the policies adopted to mitigate its effects on the Spanish
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Table 1 Participants’ characteristics. Male Profession: Nurses Doctors Province: Valencia Alicante Area: Urban Rurala Type of care: Primary careb Secondary carec Workplace: Public centers Privatized centers Private sector Total
Female
Total
2 9
3 7
5 16
7 4
7 3
14 7
4 6
7 6
13 12
4 7
4 6
8 13
7 4 7
6 2 2
13 6 7
11
10
21
Note: When totals exceed 21 this is because the interviewees worked in more than one setting. a Rural Includes Hospitals in middle sized towns covering villages. This included two private hospitals. b Primary care also includes occupational health and one interviewee from the ambulance service. c Secondary care includes specialist consultants working at public polyclinics or their own private clinics and an interviewee working in long term care.
health system by means of a study of the Valencian region. It examines the effects of those reforms and austerity measures through the experiences of healthcare professionals. 2. Materials and methods Participants were selected using convenience and snowball sampling. A total of 21 semi-structured face to face interviews with healthcare professionals were conducted during May and June of 2013. Five nurses and sixteen doctors, with regular contact with patients from a wide range of specialties were interviewed. They worked at different centers in the public, privatized and private sector, both in urban and rural areas. The questionnaire covered the perceived current and long term effects of the financial crisis and austerity measures on population health and the healthcare system; the ethical dilemmas faced by the professionals, their perception about policy development; the impact of specific policies; and their proposed solutions to the crisis. The questionnaire was designed using an iterative process to include new topics as they arose during the interviews. Table 1 describes participants’ characteristics. The study received ethical approval from the Ethics Committee of the London School of Hygiene and Tropical Medicine. The interviews were recorded and transcribed in full. All participants were presented with an information sheet, and consent was obtained for the interviews to be audiorecorded. All interview materials were stored securely to assure confidentiality. Once transcribed, the data were analyzed and coded using inductive approach and thematic analysis supported with QSR NVivo 10 software. Each excerpt also includes the number of the interview so that extracts from the same individual can be linked.
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We coded all interviews using an inductive approach, drawing on techniques from the constant comparative method, such as line by line analysis of early interviews, naming each line and segment of data, the use of subsequent interviews to test preliminary assumptions, and the comparison of codes and cases across our data set and other literature [14,15]. Excerpts and codes were discussed line among the authors to explore the themes that were emerging. In order to ascertain saturation, we identified deviant cases and explored them further. We have organized this paper around seven main themes following from the analysis of the data: perception of the impact of the financial crisis and austerity measures on population health; the effects of austerity measures on the healthcare workforce and quality of care; perception of the introduction of copayments and their impact; views on the Royal Decree and its impact; views on models of provision and the privatization process; governance of the health care system; and the solutions proposed by health care professionals.
3. Results 3.1. Perception of the impact of the financial crisis and austerity measures in population health Participants were asked whether they had experienced a change in the type and incidence of diagnoses since the outset of the financial crisis. Health care professionals reported examples of patients whose nutrition was severely affected. It was reported that families were being pushed into buying less food or cheaper options “now the main problem (of the Spanish population) is what and when to eat, it is not being able to pay the bills, it is to be able to feed your children (I09)”. As one doctor warned: Soon cases of malnourishment and even undernourishment will be noticeable. I won’t compare them to statistics of developing nations, but for a developed country they will be striking (I04). Several interviewees suggested that less food intake led to hunger and malnutrition while substitution of nutritious foods for cheaper and less healthy foods could lead to obesity, and difficulty adhering to diets and nonpharmacological treatments. Regarding mental health conditions, most healthcare professionals perceived an increase in levels of anxiety and depression due to the economic crisis. These were seen as having negative repercussions for existing physical ailments as well as giving rise to psychosomatic problems. An increase in the number of suicides was reported. However, while some mental health professionals perceived increased rates of anxiety, few reported an increased incidence in major psychiatric disorders. As one interviewee worried by this occurrence explained: No, we don’t think that the number of patients with mental illnesses has increased; nonetheless we were able to perceive, at some point, that there is an adaptive reaction of the citizens with anxiety and depression symptoms due to the socioeconomic context. [. . .] A process of great
suffering and stress is generated, which is more a worrying than a mental illness (I01). Health care professionals noted how some patients were suffering health problems due to the obligation to assume greater responsibility of caring for their dependents. This was exacerbated by cuts to social care budgets and insufficient household resources to pay caregivers or care homes. A nurse working in primary care of a rural health center explained: There were people in a home care that had to leave. In fact here there was a patient that was taken out of home care. He had an 80 year old brother, and he was almost 90. He had a tracheostomy, urethral catheter [. . .] The brother couldn’t pay for the home care bills anymore. He took him home and in less than two weeks he was taken to hospital (I11).
3.2. The effects of austerity measures on the healthcare workforce and quality of care The healthcare workforce was affected by cuts in the number and working hours of staff, exacerbated by forced retirements. Some participants expressed their anger about wage cuts and not having enough staff to cover those on leave: The crisis has justified everything! Everything aimed towards reducing expenses, from stationery to not substituting colleagues during long leaves, loss of employment, people that leave and their positions are not covered. . . everything everything! (I13). There were also reports of stricter control of sick leave, reduced funds for research and inappropriate use of doctors in training (residents) “many times you take decisions that you shouldn’t and do things that you shouldn’t be doing as a resident [. . .] they just don’t open new positions (for doctors) despite the growing demand (I20)”. The increased workload, further pressure at work, a decrease in the number of referrals allowed, and reductions in equipment, were all believed to have had an impact on the quality of health care “There is an increase of workload for the remaining staff, which decreases the quality of care (I13).” Several interviewees also complained about the increase in waiting times and overcrowding of hospitals and primary care centers as well as emergency services. The two next quotes are examples of the many reports: The quality of the assistance is decreasing, completely, the waiting times for interventions and consultations are growing. [. . .] Hospitals and primary health centers are overcrowded (I14). I-Do you think it is really affecting the quality of care? I20-Without any doubt, it doesn’t seem logical to me that a 83 year old granny is waiting up to 3 days in an Emergency Room because there are no beds available [. . .]. Now they are putting chairs in between ER beds because there are no beds, to avoid hiring more nurses, not to hire more doctors, not to hire more porters (I20).
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Interviewees also mentioned how it was becoming more difficult to transfer patients to more appropriate facilities when specialist care was needed. The cuts have also meant a decrease in the number of beds and out-of-hours availability of emergency care in rural settings, as a doctor explained:
The majority of health care professionals, who were against the introduction of copayments, shared stories of patients being unable to pay for medication. For example a surgeon recalled the story of a patient not taking his antirejection medication because he could not afford to pay for it, and later dying of a related complication:
By decreasing the numbers of hours that staff work, healthcare coverage has decreased [. . .] this center at 9pm is already closed, it really affects the user [. . .] The rural population is the most affected (I10).
R-So, when a patient comes and tells you that he can’t afford the drugs, you pick the drugs he’s got and prescribe the minimum, so at least he stops using the more expensive and less useful pills. . . I-And that affects their health? R-Yes, he was a cardiac transplant patient, he stopped taking his medication and died. I don’t know if he died due to an infection or varicella. I-And he stopped taking it because of this issue (copayment)? R-Yes, he stopped taking it because he didn’t have enough money (I20).
Most interviewees reported negative effects on the quality of care provided, which they linked to worse health outcomes. The above mentioned closure of emergency services and ambulances was believed to increase the risk of avoidable deaths in the rural population: There were cuts in the ambulance services, hence, ambulance arrival time has become longer from 5 to 15 minutes, and this translates into a risk of avoidable deaths (I09). A pediatrician complained about the difficulty of providing basic care due to the scarcity of basic sanitary pads for women and even restrictions of drinking water for patients: For example during deliveries [. . .] the lack of specific things like having to ask for sanitary napkins for the bleed postpartum and you have to get the things with a dropper (one by one). They don’t want (to give it). Plus a sick person being there and not having water provided for example. . . I think it shouldn’t be this way (I15). A few professionals reported that quality of care had not been compromised and may actually have improved due to some of the changes introduced or to the resilience of healthcare professionals. However, most suggested that, in the long run, the cuts would have a negative impact on patients: There is pressure, but I see it more from an administrative point of view. I think the service, as a health service, hasn’t been affected, but it will end up being affected. They are going to start to restrict procedures. . . (I04). Health care professionals working in the private sector reported a decrease in the number of patients and insured people, and cuts in staff and available resources. As a doctor recalled “there are less people with private insurance and therefore we have fewer patients in the private sector, moreover the companies (insurance) have a tighter control on expenditure (I02)”.
3.3. Perception on the introduction of copayments and their impact Some interviewees supported the introduction of small fees both for pharmaceuticals and for access to services, as a way of “educating” the patient or to raise awareness about the cost of care “I think that they (the users) are gaining more consciousness of the use of the public (health) system (I06)”. One interviewee argued that these measures needed to be coupled with the appropriate education.
Another health care professional working in the emergency services recalled an ethical dilemma arising from an inability to provide free medication when needed. In this account she provides the example of a mother unable to afford medication to reduce her child’s fever: For example, a dilemma occurs when a person comes to emergency services, and you know, she says she hasn’t got the 2 euros for the Apiretal, not even the Dalsi (both are common analgesics) for her son. You feel like giving her the Apiretal and the Dalsi for the baby. You know the mother doesn’t have the income to buy it and the child has fever. It is not the child’s fault. . . (I14).
3.4. The views and impact of the Royal Decree There were mixed opinions about the new Royal Decree, Law 16/2012, introduced in 2012. The Royal Decree has meant that whole groups of the Spanish population (mainly undocumented migrants) are excluded from preventive and primary and secondary care services coverage. Around a third of professionals supported the implementation of the decree, especially the way that it targeted the nonSpanish population, both migrant and tourists. However, the majority of interviewees were against it and defended universal health coverage as a basic principle of the Spanish health system, a feature all interviewees reported being proud of. The following was a nurse’s opinion: Terrible! As a nurse, terrible! Because for me care is universal, I don’t pay attention to race, color, nationalities. . . Because the Spanish health care system, which I am very proud of, was of universal coverage. It means, whoever comes to this country, has his health assured, at least his health care. It (the new decree) seems terrible! (I12). Around half the interviewees had doubts about whether the Royal Decree was being implemented, either because managers would not impose it or because health care professionals were finding ways to disobey it and provide the same care as before. However, there was also a sense that this would not last very long:
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P-There is an Argentinian family that has all the correct documents to receive healthcare. But one of the sons is over 18 and he doesn’t have them. He is a psychotic with a schizophrenic disorder and is impaired, so he has no healthcare coverage. I-And how did you proceed? P-Looking for subterfuges in a thousand ways, and there is still around two years for a legal process, an administrative process, to obtain the coverage. Meanwhile it is discussed, it is enquired, it’s done, but for now it is given (the care) [. . .] but I know that at any point it will be removed (the right for coverage) (I13).
3.5. Comparisons of different models of health care provision and views on privatization During interviews, health care professionals talked about their experiences and perceptions of the effects of the financial crisis in the public and privatized centers, in some cases comparing both systems. Some interviewees working for the private sector believed that public sector professionals worked fewer hours and had no supervision or insufficient incentives to improve productivity. A general perception of ineffective management persisted, especially regarding leadership and use of resources: Everything is underused [. . .] There are specialties where the operating rooms are not used sufficiently [. . .] And then there are some mistakes with appointments. . . like suddenly the patient is appointed for surgery but has no consent signed or hasn´ıt been seen by the anesthetist (I18). A few suggested that improvements were taking place in these areas since the introduction of austerity measures. For example a nurse reported “right now the administrative system has changed, including modification of drug prescription dispensing. . . well done, I think it is logical and fair (I08)”. Some interviewees highlighted the difficulty in comparing public and privatized facilities due to the different level of resources, institutional arrangements and the difficulty in disentangling the effects of the financial crisis. Overall, only a few professionals had a positive perception of privatized centers, reporting that there was better management, less wastage and the quality of the care was similar to that provided in public centers. Some interviewees expressed negative opinions of private hospitals in Valencia. Complaints included early discharges, risk selection, and cream-skimming of patients to increase profits. It was argued that restriction in the number of referrals and early discharges could be damaging to patients’ health. The story of a patient whose leg had to be amputated due to not being transferred on time was shared by one participant: A patient arrived after a motorbike accident. And he happened to be from Valencia, but because it’s better for the hospital if he stays in this hospital, they didn’t refer him (to the appropriate hospital)[. . .] They did it (the amputation) because he had been here retained for three days [. . .] Then they send the patient outside (to another hospital), in a desperate manner, because they had already messed up.
Imagine, of course horrible things are happening. Horrible! They don’t want to refer anybody to another hospital, and this is not ethical, not ethical at all (I21). Overall, most healthcare professionals were against further privatization. They argued that this model pursued profits and prioritized cost saving at the expense of adequate patient care “everything is an excuse so they can keep earning money, the less you spend, the less (patients) you admit, the better doctor you are, those are the only criteria, the patients are the least important (I19)”. 3.6. Governance issues: a major concern The perception of corruption and mismanagement was often mentioned in interviews and at all levels of the health care system. At facility level, interviewees reported drugs being taken home regularly and heard cases of expensive equipment being stolen from public hospitals. Professionals working in the private sector reported knowing of cases of corruption within their centers. There were particular concerns about the potential for corruption in private concessions delivering public services, with frequent calls for tight control of these arrangements during interviews. At the system level, politicians, policy makers and top level management were blamed for not having the knowledge, experience and information needed to take decisions that would improve the health care system. Moreover, most interviewees perceived a lack of planning and claimed that decisions were made precipitously. Healthcare professionals complained of being excluded from the design and implementation of healthcare policies. Participants highlighted a lack of consensus in the introduction of healthcare reforms and a low level of engagement with associations and citizens. In addition, they expressed concerns regarding a lack of transparency and communication of the new policies. As a result, health care reforms were believed “to be doomed to failure”. In the following quote a doctor describes how decisions are normally made by those who do not know about the topic: So the clinical consequences are not taken into account because (the decisions) are not taken by those who know about the topic. Of course! (I05). 3.7. Solutions proposed by health care professionals Often healthcare professionals felt puzzled and found it very hard to propose a specific solution to the new challenges. Privatization, the Royal Decree and user charges were considered, by a few, as possible solutions. Conversely, the majority saw that steps required for a solution were to stop privatization or abolish user charges and the royal decree. The provision of education for the population on the appropriate use of health services was often advocated as a possible alternative to reduced health care expenditure. The solutions that were most often mentioned by health care professionals included improved governance and management; the need for optimization of resource use; decreased wastage; the use of evidence-based guidelines; better staff management; improved productivity;
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performance measurement and more auditing. As a healthcare professional mentioned: I believe there must be a continuous optimization of health systems. There must be an optimization and the ability to assume errors through non punitive audits with the goal of keeping improving (I01). There was a demand for accountability, responsibility and increased transparency concerning the activities and decisions made by all parties involved, specifically healthcare professionals, managers and politicians. As a doctor demanding transparency explained: Transparency, there is very little. Transparency is the “quid” of the issue. Well, transparency does not exist. But it does not exist at a hospital level and I don’t believe either at political level or national level. . . (I17). Finally, their participation in decision making was seen as essential for success although there was an overwhelming view that so far they had not been consulted throughout the process of agenda setting and policy making.
4. Discussion The results of this paper shed light upon health care professionals’ perceptions of how the financial crisis and austerity measures are affecting the functioning of the Spanish health care system in the Valencian Autonomous Community. As perceived by healthcare professionals, austerity measures are having an adverse impact on the quality of healthcare provided and health outcomes of their patients. They foresee more negative effects. The health of the Spanish population was perceived as being compromised by the financial crisis, mainly with increases in mental illness and reported cases of malnutrition. Austerity measures, particularly in social services, had also led to increases in anxiety. In the health care sector, views were divided about certain measures, such as introduction of copayments, the implementation of the new Royal Decree or more sanctions on sick leave. But despite this disagreement, the majority recognized the negative health consequences of these measures and most reported being willing to take measures to circumvent them. Several professionals believed that the public sector was making strides in improving efficiency, and a few others believed that the privatized model was a possible solution. However, the majority of interviewees viewed this privatization process with concern, due to the profit maximizing behavior of private companies associated with impaired quality and worse working conditions for healthcare professionals. Some professionals inside the privatized model described severe cuts in referrals and early discharges that harmed patients. This may be a result of the current economic incentives derived from provider payment mechanisms. The system of governance has failed in the eyes of healthcare professionals, with serious issues ranging from corruption inside and outside the health system, lack of participation, transparency, and accountability. Alarmingly, the results confirm that all five of the policy responses
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to the financial crisis identified by Mladovsky et al. (2012) as undermining health system goals have been adopted in the Spanish health system [16]. They include attrition of health workers by wage cuts, forced retirement and worsening working conditions. There were also suggestions that waiting lists for essential services were increasing; some services, such as emergency care, were reported as no longer being accessible in rural areas; user charges have been applied to essential drugs; and population coverage has been substantially reduced by the new decree. The new Royal Decree is a complete turnaround of the vision of universal coverage and free services at the point of delivery, and experts have suggested that it might be in conflict with the Spanish Constitution [8,10]. It establishes a divide between populations entitled to public healthcare and those who will be forced to pay for their care even when accessing public providers. By deliberately targeting groups such as immigrants and people that have not had an opportunity to contribute to social security, it establishes a new paradigm of social justice in the Spanish care health system. This exclusion of part of the population is most surprising in an era when the WHO is promoting a strategy of universal health coverage globally. The findings of this study highlight the adverse effects of copayments in the Spanish population. There were reports from patients not being able to afford medication for their children and of patients not taking their medication after surgery, in one case viewed as contributing to their death. There is substantial evidence of the negative impact of user charges in healthcare, showing how even small fees have a negative effect on efficiency, equity, health outcomes and cost containment [17,18]. Furthermore, recent evidence shows a deterioration in health outcomes in hypertensive patients when user charges are increased [19]. These consistent findings with others conducted in Spain [20,21], which resonate with the experiences of the health care professionals interviewed in this study, suggest that the removal of user charges would facilitate better health outcomes. Many interviewees perceive a political agenda behind the process of privatization, consistent with previous research on this matter [22]. The potential for corruption in Spanish healthcare is not only perceived nationally but at an international level [23]. Recent evidence by the Valencian authorities corroborates the concerns of some healthcare professionals about the externalization of health services leading to a greater expenditure than those provided by the public sector, amounting to a staggering D 16.7 million in Valencia [24]. The added value of this study lies in its ability to capture perceptions that challenge official narratives. It also provides accounts of what is happening in areas where there are gaps in government data and provides a finely textured picture of what is happening on the ground. A limitation of this study is that it only covers one Autonomous Community in Spain, and therefore it is not representative of what is happening elsewhere. Since the management of health care is devolved to each region, further research is needed in other regions of Spain to have a whole picture of the current situation. The Valencian region is atypical in several ways. The health care cuts have been introduced
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at a slower pace than in other Autonomous Communities such as Catalunya and Madrid; it is a stronghold of the Conservative Party (Partido Popular); it has large numbers of tourists, resident British pensioners, and immigrants working in agriculture; as well as being the first to introduce the Alzira model of public-private partnerships which has been highly contested in the rest of Spain. One of the strengths of this study is that, to the best of our knowledge, it is one of the first studies conducted ascertaining the views of health care professionals in Spain, and the first exploring their views in the region of Valencia. 5. Conclusion The results of this study already highlight growing problems with affordability of medicines and access to healthcare, providing sufficient justification to lower copayments and increasing exemptions. Further research is needed to evaluate current policies, with an emphasis on user charges and the effects of the Royal Decree; an assessment of systems of governance; a review of decision making processes in respect of resource allocation and use; and a consideration of the effects of economic incentives on provider payment mechanisms in privatized providers. The proposed health care reforms were highly contested, with opposition from many professionals who expressed serious concerns about poor governance and widespread corruption. There is an urgent need to establish a policy making process that is transparent and based on the best available evidence and sound evaluations so that the Spanish population and health care professionals regain trust in their institutions and so that the proposed reforms do not further damage the most vulnerable in the population. Conflict of interests No conflicts of interest. Funding No funding was received in order to conduct this study. Acknowledgements To all healthcare professionals that helped making this research possible. References [1] Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu S, Stuckler D, et al. Financial crisis, austerity, and health in Europe. Lancet 2013;381(9874):1323–31.
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