Elsevier

Health Policy

Volume 119, Issue 1, January 2015, Pages 100-106
Health Policy

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

https://doi.org/10.1016/j.healthpol.2014.11.003Get rights and content

Highlights

  • Austerity measures were imposed on the Spanish health care system.

  • Healthcare professionals reported increases in mental health and malnutrition.

  • They perceived that the quality of care and health outcomes had deteriorated.

  • The proposed reforms were highly contested and opposed by most professionals.

  • There were concerns around poor governance and widespread corruption.

Abstract

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.

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 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. 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], [4], [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 co-payment 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 €8, €18, or €60 monthly payments, depending on their pension income [3]. With the new increases in copayments, those earning less than €18.000 per year have to pay 40% of the medication and those earning more than €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 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.

Section snippets

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

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

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

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

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 (24)

  • El Pais

    La plantilla de la sanidad pública cae a cifras récord: 28.500 menos en dos años

    (2014)
  • H. Legido-Quigley et al.

    Will austerity cuts dismantle the Spanish healthcare system?

    British Medical Journal

    (2013)
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