Health System Evolution: Reforms, Challenges & Sustainability
New Horizons and Health System Reform Needs
International Context of Health Services
The rapid evolution of the Spanish National Health System (SNS) in recent years has placed it on par with those of comparable developed countries, despite differences in structure, organization, and operation, as they share common situations and problems. Economic, technological, and societal factors equally affect all countries in Western Europe. Consequently, the evolution of different health systems has led them to address these changing needs, which are outlined below:
- Cost Containment (1970s and early 1980s): The immediate response of all governments during crises is to cut budgets, mainly in social policies such as health services or education. Thus, the oil crisis of 1973, with respect to health, focused on limiting hospital budgets, staffing levels, and wage freezes, slowing the creation of new centers, and transferring powers to the private sector, among other measures.
- Planner Rationalism (1970s and early 1980s): Faced with financial problems, a different approach was needed to address the emerging needs in health systems. It was concluded that increased health spending does not necessarily mean better health. Therefore, greater efforts were made in promotion and prevention, with greater empowerment of primary care and hospital services, all aimed at improving health before resorting to healthcare.
- Managerialism (1980s and 1990s): Attempts were made to improve the efficiency of health facilities, especially hospitals, by applying organizational skills from business management.
- Introduction of Market Policies and Contracts (1990s): This sought to create a competitive context (e.g., among public hospitals) with a contract system and new ways of managing institutions that shift risks and benefits from the public system (state, autonomous regions) to public providers (professionals).
- Clinical Management and Governance (Late 20th Century): The primary objective was to improve the quality and effectiveness of medical units and practices.
All these patterns remain relevant today, not in their pure forms, but intermingled in various ways. They influence other health systems to different extents, depending on the political circumstances of each country.
Spanish National Health System: Key Weaknesses
The problems the Spanish National Health System (SNS) faces in the 21st century, after rapid evolution over the past 25 years, are mainly related to four basic aspects of health and the relationships established with system users. These problems are conditioned by: medical advances and research; the economic sustainability of the system considering the interests of each state; the lack of resources (whether economic, authoritative, or informational); and the role the patient has come to play within the system.
Advances in Medical Practice and Research
It must be emphasized that in the information society, attempting to cover all available information is an impossible task. Likewise, in medical practice, the volume of information available to physicians is unmanageable. This situation leads to greater specialization and the need to establish relationships with different areas of the profession. Consequently, investment in training is necessary. However, the higher cost and profitability of this training are called into question when health is managed like a private, profit-driven company. It is necessary to approach medical practice from a perspective where medical knowledge and its application can be managed. This requires establishing more professional human resource management policies that help improve professional skills, with models that grant greater autonomy and organizational capacity to medical units.
Economic Sustainability of the System
The health financing system for the Autonomous Communities, approved in 2001, included funding from 2002 after INSALUD (the former National Health Institute) completed its transfers. This model encountered financial problems within two years, necessitating additional funding, which was agreed upon at the Conference of Presidents in Madrid in 2005. It became apparent that the financing design for the Autonomous Communities did not adequately consider the interests of different levels of government (central and regional) concerning their respective competencies and responsibilities. This highlights the need for a new design for autonomous community spending relative to their income.