CRITICAL STEPS IN EUROPE TO SET UP PHC UNDER
CONDITIONS OF RESOURCE CONSTRAINT;
THE CASE OF THE MEDITERRANEAN COUNTRIES
Juan Gérvas and Antonio Durán
for Oxford Policy Management Ltd for the Department for International Development (United Kingdom), 2004, with the support of the Georgia Government
Contents
I Introduction......3
II. Greece II. a. PHC in Greece as a case-study......5
II. b Policy analysis of the Greek PHC case......8
III. Italy III. a. PHC in Italy as a case-study......11
III. b. Policy analysis of the Italian PHC case..........15
IV. Portugal IV. a. PHC in Portugal as a case-study......18
IV. b. Policy analysis of the Portuguese PHC case......21
V. Spain V. a. PHC in Spain as a case-study......24
V.b. Policy analysis of the Spanish PHC case......30
VI. Conclusions......33
INTRODUCTION
When countries of central and eastern Europe (CCEE) confronted the changes associated with what has been described as “the Berlin Wall fall”, they clearly looked to the West for models. Germany, for example, is one of the richest countries of the world (and culturally and geographically very close to many Eastern European countries), so its way of living and its economy was seen as an ideal reference. It is clear that their move towards social insurance systems and their wish to raise traditionally very low provider remuneration levels, together with other factors, have made the German health system very attractive.
However, when it comes to issues of organization, provision and financing of PHC, wealthy countries might not be the best example. The German PHC system in particular is not considered a model by other countries of western Europe. German PHC is in fact very weak, and the whole system costs too much, even for a rich country (1,2).
Experience has supported those fears. For example, the move in the 1990s of the Czech Republic to adopt key features of the German point system, with free access to specialists and fee-for-system payment in ambulatory care (before the development of adequate information systems, and before the establishment of a process of negotiating fees) proved catastrophic, with loss of expenditure control, huge cost inflation and serious social problems within a few months of initiating the new system (3).
The adoption of the German system shows the strong informal policy power of Czech professionals at that time, supported by external agencies, as the World Bank and others. It shows also the weak formal and informal policy power of the government authorities (more or less brilliantly supported by WHO) but almost void of financial, knowledge and social resources.
Other document by this Consultant commissioned by Oxford Policy Management Ltd for DfID in the context of the Georgia Health Sector Reform Programme - CNTR 02 4201, Primary Health Care, for the Human Resources Policies Work Stream, has made the point that there is not enough research basis to speak about best practice models in PHC in Europe. In more limited sense, however, there is consensus that western Europe includes a few countries that can be considered good PHC practice models. Denmark, the Netherlands and the UK have broken the typical PHC negative circle of low social esteem, poor earning, and heavy competition with specialists. Spain is close to these countries in 2004 after its PHC was successfully reformed in the 1980s.
At that time, Spain was not a rich country. In the 1970s it came out of a hard dictatorship and democracy returned. The reform of PHC began in the 1980s, following the political program of the Socialist party in power from 1982 to 1996. Much can be learned by analysing Spain as a benchmark, and comparing it with other Mediterranean countries (Greece, Italy, and Portugal) [in alphabetical order], that have been less successful in developing a solid PHC. All four belong to the European Community (now the EU), and Spain, Portugal and Greece were (and are) included in the group of less affluent developed countries (4).
national health services in Greece, Italy, Portugal and Spain was influenced in particular by the British and Nordic national health systems, and by the WHO policy of emphasising PHC and Health for All (5). Later on, membership of the European Union forced them to control the national budget, according to the Maastricht Treaty in 1994, and to act according the new “Euro” financial discipline in 1998.
Public finance, which includes compulsory health insurance contributions, remains the main way to fund access to health care in these four Mediterranean countries, and its role was extended with the moves towards ensuring universal coverage. The worsening economic climate in the world during the late 1970s and the 1980s (the “oil crisis”) exacerbated the difficulties of the reform. It therefore looks fair to compare and learn from their success and failures in reforming PHC when Georgia is going through a rather similar process of change.
I. GREECE
I. a. PHC in Greece as a case-study
The democratic Greek Constitution of 1952 was reformed and approved in 1975, at the end of the “Colonels” dictatorship (which lasted from 1967 to 1974 and followed the track of a previous fascist government before World War II). The Greek Constitution states that all citizens have equal right to health care. In addition it refers to the responsibility of the State to “care for the health of the citizens and to take special measures for the protection of the young, the elderly, the handicapped and the indigent”. In 1981 Greece became a member of the former European Community. With 10 millions, the population is unevenly distributed over the country as more than 30% of it lives in Athens. In 1991, the Greek Gross Domestic Product (GDP) per capita was 16,137 dollars (at purchasing power parities) (6).
In 1983 the then Socialist government passed a law on the introduction of a National Health System, with great political support, thus challenging the existing social security-based health care financing. The reform followed many of the Doxianes Plan recommendations issued in 1980. The National Health System Act was an attempt to create a more comprehensive public scheme (until then public coverage was 88%, and almost did not exist a public PHC system) as well as to increase control of the private sector. It was a decided step to change the financing of its health care from a Bismarck system to a tax-financed Beveridge system (7).
Greece faced great obstacles in such an endeavour, because it had to transform a health system which comprised different private health insurance providers to one with public health services providers in a time of adverse economic situation (as already mentioned, the “oil crisis” was having at the time a very negative impact on the global economy).
At the end of 1983, a Ministerial Committee for Health Policy was established under the chairmanship of the Prime Minister. Its main task was to coordinate all health-related agencies in formulating and implementing a common health policy. As a consequence, the Ministry of Health and Social Security was reorganized in 1985 as the main agency responsible for the administration, organization and provision of health services. Under the Minister there were two Deputy Minister, one of them responsible for Social Insurance, and the other for Health and Welfare Services.
In a hierarchical order, immediately below the Minister was the Central Health Council, established in 1982, and consisting of 24 members who were representatives of physicians, pharmacists, and nurses associations, medical schools, trade unions, civil servant associations, and urban (industrial workers, IKA) as well as rural (agricultural workers, OGA) insurance associations (sick-funds). There was a strong opposition of professionals and sickness funds which could at least slow the reform process.
The Council was invested with many tasks and responsibilities, such as:
4) monitoring the planning process, and proposing corrective measures whenever necessary, and
5) coordinating and controlling the regional health councils and advising on the allocation of economic resources between regions.
The Council set up a committee on “Primary Care. Organization and manpower planning of the primary health centres”. This committee’s mandate was aimed at:
1) achieving full time employment of doctors in the public health system, thus diminishing simultaneous attachments to both public and private practice,
2) developing a national network of health centres with teamwork and salary system, following WHO recommendations (Alma Ata Declaration, and Health For All objectives),
3) promoting general practice as to balance the trend towards specialisation,
4) introducing a pro-coordination reform (general practitioners as gatekeepers), and 5) training PHC medical and nursing staff.
General practice did not exist, and hospital out-patient care included services provided by paediatricians, internists, obstetricians, and other specialists (8).
In 1991 and 1992, the reform was corrected with comparatively increased emphasis in private provision of health care, and the introduction of cost-sharing (9,10). Because of the Maastricht Treaty stipulations, a new Socialist government appointed in 1994 an international committee to make an independent review of the Greek health system and suggest how to increase efficiency and equity. The central recommendation of this committee was to establish PHC with self-employed general practitioners and capitation system. It highlighted the need for introducing emphasis on general practice in medical shools, and for developing programmes for the training of managers, public health doctors and general practitioners. Also, a Medical Council should be established to police the ethical standards of the medical profession and stamp out illicit payment of every kind to doctors (11). Most of these provisions were never implemented because delays and a subsequent change of government stopped the implementation process. Instead, a new correction increased again private provision in the late 1990s and early 2000s, emphasizing patient freedom of choice and private initiative.
After more than 20 years, despite improvement (for example, public coverage reached 100% from 1985 onwards), the Greek health care system still has many features of former days:
a) the government has only been successful in developing health centres in rural areas. Those health centres are run by the national health system and the sickness funds, and are staffed with salaried doctors and nurses. The health care budget has not been sufficient to fund the necessary development of facilities and the plan was never fully implemented,
c) there are notable differences in the services and coverage provided by the many health insurance funds,
d) the state supplies free of charge health care mainly through a network of hospitals in urban areas and health centres in rural areas; the private sector, however, is still important, and of increasing importance in service delivery,
e) physicians work frequently in public hospitals or health centres in the morning (salaried) and in private clinics in the afternoon (fee-for-service payment),
f) there is an oversupply of physicians (mainly specialists) and hospital beds (although rather declining),
g) there is a severe shortage of nursing personnel,
h) “black money”, “under the table payments” and tipping practices are common, as there are hidden extras frequently both to private and public general practitioners and specialists,
i) in 2001, almost 45% of total health expenditure was private (665 out of a total of 1,511 dollars per capita [for comparative purposes, it must be noted that according to
OECD Health Data 2003, the average private health spending in the 22 OECD European countries (including Czech Republic, Hungary, Poland, and Slovakia) was 25%, 505 out of 2,049 dollars] (6),
j) Greece join Austria and Portugal (and the USA) in being the only countries of the OCDE where total physicians visits appear not to be distributed according to need, although lower income groups use general practitioners significantly more often than higher income groups. Adjusting by region reduces the degree of inequity in Greece, suggesting that the income-related inequities in specialists use are, at least in part, associated with regional differences in access to such care (12),
k) the gate keeping role of general practitioners does not exist in practice (it is just a formal role) (8), and only rural general practitioners have patient list,
l) paediatricians work in health centres as (some kind of) general practitioners for children,
m) after medical graduation one year of practice in PHC in rural areas is compulsory (but many physicians feel the countryside experience of general practice as almost a punishment before entering specialist training) (8),
n) in 1995, the practice primary score of Greece was 4 (the best score being 20), one of the lowest in Europe (but still better than Germany, 3, Switzerland, 2.5, and France, with 2). It is important to note that the score has not changed over time (it was 4 in 1975 and again in 1985) (2),
p) in 1996, 24% of the Greek population was very dissatisfied with the way the health care is run (the second highest rejection rate, after the Italian population) (14). The situation has not improved over time (in 2003, total satisfaction was 4, in a scale from 0 to 10) (15), and
q) the Greek Association of General Practitioners is powerful, but devotes its power mainly to union tasks; as a consequence, research and knowledge production in general practice are underdeveloped.
I. b. Policy analysis of the Greek PHC case
This case study shows the struggle of formal policy power (mainly the socialist government of the 1980s and 1990s) to develop PHC and a Beveridge health system with almost no control of any source of informal policy power. In fact, insurers and professional associations usually have more informal power than governments.
The existing Greek health system was and still is fragmented and with no decentralization at all. At the same time, there is a plethora of social and private insurance plans, and public as well as private providers, especially in urban areas. The 15 regions have almost neither health policy nor decision-making power. As in Portugal (see below), governance of PHC is centralized within a national health system (7-10).
History might have the key to explaining the weak position of a democratic party in the government. Greece has had frequent turbulent times until 1974, with a fascist administration before World War II and a hard dictatorship from 1967 until 1974. A national social security system (IKA) was established in 1934 for industrial workers with coverage of around one third of the population. This IKA developed it owns health care infrastructures for its insured population. Staffed with a number of specialists, they provided free at the point of use care to fund members.
The three more important collective stakeholders (government authorities, insurers and professionals) have played their role an used their power in changing such a health system without general practice, from a Bismarck system to a Beveridge one based in PHC. There was strong opposition of the professionals and insurers. Doctors used their influence to block badly needed reforms, probably to preserve a system that gives them financial abundant illegal incomes (tipping practices).
The socialist government utilized its formal policy power, and the Constitution, to launch the reform with the National Health System Act. However, it never had enough financial and ownership resources, so health centres were a reality only in rural areas, and the health care budget has never been sufficient to fund the required development of facilities and workforce. The State authorities lack also strong knowledge and information resources, as their main source in this regards was the external informal policy power of WHO [Alma Ata Declaration, Health for All, and the Finnish’ health care system as best practice model]. But knowledge and information resources are more important in Greece than elsewhere.
different political sign, as it usually happens after experiencing a dictatorship (societies are left morally and ethically handicapped for decades later).
Insurers and professionals had important formal policy power in the Central Health Council in the 1980s. Having a Bismarck system at that times meant that their networking allowed them to develop neo-corporatist schemes, based in joint decision-making by the State, insurers and professionals. Moreover, insurers had the ownership and financial power. The Social Security budget is always bigger than any other budget in the country. In the 1980s, the existence of one Deputy Minister of their own in charge of Social Security, with more power than the Deputy Minister of Health and Welfare, made the day-to-day management rather difficult (later on, Social Security was moved again back in the Ministry of Labour).
Not surprisingly, workers and trade unions supported in the Central Health Council and everywhere “their” own sickness funds (IKA; OGA, and the small ones, as well as their organization and role in health care supply). Workers of the banking sector and other powerful business had, and still have, better services and coverage.
As a consequence, and as explained above, Greece has still a health system with many of the Bismarck model features; in 2000, almost 50% of total health care was social insurance-financed.
Also, without previous experience of general practice, PHC development in Greece was rather weak. Patients had had personal experience in using specialists as some sort of general practitioners. The health system was and is hospital driven. There is a lack of properly trained PHC management, medical and nursing personnel. And to make it worse, the few general practitioners worked in competition for first patients’ contact with ambulatory specialists. Thus the pro-coordination reform, the gate keeping system, was only a formal, administratively hierarchical decision, never a functional change. The referral system was considered a failure in the whole country (7,8,11).
General practitioners have at least succeeded in giving more care to poor people, but income related inequities in specialist care use means than urban areas have an oversupplied of specialists who give, probably, unnecessary care to richs.
The perception of public services in Greece is very low, as a result of shortages and long waiting time (in a country with oversupply of doctors!). There also are serious deficiencies in the public health service infrastructure. As these deficiencies result in public provision of a limited range of services, the public health sector is very weak.
Overall, general practitioners lacked in Greece social trust and were never able to break the already mentioned negative circle of low self respect, poor education, poor earnings, scarce research and heavy competition with specialists and hospitals. PHC has always been under-funded, and under-developed. Research was almost non-existent, and few universities, as the University of Crete, give emphasis to PHC.
II. ITALY
II. a. PHC in Italy as a case-study
Italy has a population of 60 million, and it is a member of the European Union from its early foundation as European Community. It is one of the wealthy countries of the world, with a GDP per capita, in 2001, of 26,345 dollars.
The Italian Constitution (1948) was approved after World War II, abolishing the Constitution of the fascist government before the war. The new Constitution defined an administrative organization of Italy in 20 regions, with 5 of them having a special status because historical and linguistics reasons (Friuli-Venecia Giulia, Sardinia, Sicily, Trentino Alto Adige, and Valle d’Aosta). The devolution of power to the regions has been an evolving process, and a very important one from the point of view of the health system reform. It began in the immediate post-war years, languished until 1971, and accelerated from the late 1980s, with the regions being transformed from what were essentially administrative apparatuses into real political entities (1,8,16-18). After the constitutional amendments approved in 2001, Italy can now be regarded as a quasi federal State.
In 1958, an independent Ministry of Health was established for the first time. The objectives advocated by WHO in the 1970s were adopted by Italy in terms of ensuring ideal health conditions and providing the necessary services to each citizen.
At that time, sickness funds with their direct relationship with doctors (through a fee-for-service payment system) had made health expenses almost impossible to manage, and new payments had to be increased. The national debt thus increased as the State attempted to aid insurers.
With a coalition of parties which included the then powerful Communist Party, a National Health Service was created in 1978 (Act 833) with the objectives of
1) transforming a Bismarck system into a Beveridge one, 2) giving PHC a central position in the system, and
3) improving access to the whole population (universal coverage, from 95% in 1975 to 100% in 1980).
The 1978 reform was a success regarding the abolition of the sickness funds, because of the existing division of professionals associations and the low prestige of those sickness funds.
In theory, the latest instalment of the State debt towards any insurer was to be paid in 1984-1985 (19). However, the intention to change the health system from mainly insurance funding to general taxation funding took decades, as in 1999 workers and employers contribution was still 44% of the total public health cost (the remaining 46% came from public national taxation, as well as from local and regional taxation).
Initially, measures were designed to:
1) limit expenditures and control costs,
2) reorganize the hospital network in areas where an exaggerated numbers of bed were existed (one of the main characteristic of the Italian health care sector is a strong hospital structure),
3) regulate the workforce market, decreasing the number of physicians (not so the variety: the Italian system was and still is based on developing specialized services and professionals for each health problem) and increasing the number of nurses (i.e. correcting the existing very low nurse)doctor ratio),
4) improve and established family planning centres,
5) develop mother and child health local centres,
6) transfer power to regions and local authorities, and
7) allow local health units (20,000 to 50,000 inhabitants), the daily management of health services and the contract of services through their elected committees,
8) provide care through hospitals, polyclinics, and engaged self employed paediatricians and general practitioners (who would be paid by capitation payment plus allowances, and would be given a gate keeping role),
9) improve public coverage (from 95% to 100% of the population).
The truth was that the sudden implementation of this reform increased the fiscal deficit, year after year. In 1995, the Maastricht Treaty made it necessary to review the reform in order to solve the chronic deficit and increase efficiency and equity. Doctors were allowed only one job in the National Health System. In fact, simultaneous private and public work was forbidden since 1978, but many physicians have been working both as general practitioners (with small patient list) and as hospital doctors paid part-time salaries. General managers then replaced the elected committees which used to run local health units (their number was reduced from 650 to 250, serving populations from 100,000 to 250,000). Capitation fees, which varied depending on the patient’s age, were allowed to supplemented with fees for about 20 services up to a maximum of 25% of capitation income.
In 1999, a new reform introduced new financial incentives in PHC with the objectives of
1) decreasing referral rates, 2) strengthening group practice,
3) broadening the portfolio (for example, allowances for the delivery of care to specific patient as home care for chronically ill), and
The history of the National Health Service can also be seen as an ongoing attempt to come to grips with the financial implications of expanding regional autonomy. Arrangements for financing the system were for many years characterised by a form of skewed fiscal federalism. Regions enjoyed considerable discretionary power in the expenditure side of the budget but had virtually no responsibility on the revenue side. Lacking any significant own-source revenues, the regions could not be obliged to finance their deficits. Faced with this situation, the different central governments felt obliged to resort to more or less veiled forms of under-financing.
Central-regional relationships have always been conflict ridden, with a negative effect on the health system performance and low public satisfaction with the provision of care.The situation remained stalled until the early 1990s, when a process of transferring revenue sources to the regions was launched (with an explicit mechanism limiting the financial obligation of the central government for health care). The Bassanini reform gave real power to regions, which were given freedom to spend as much as they wished to, but were obliged to guarantee a nationally uniform entitlement to all residents (“essential level of care”, “basic package”, an agreement between central and regional central governments, in addition to negotiating overall spending levels).
A peculiar feature of the Italian political life worth noting here is that governments are usually granted only a short life, with more than 50 of them in 50 years. And indeed changes mean different political options and priorities. For example, implementation of the established plan for fiscal federalism in the national health system was blocked after the election of the Berlusconi government in the early 2001.
Anyways, unable to live within the spending limits inherent in the current negotiated funding levels, regions are applying patients co-payments and are de-listing services, and these practices vary form region from region.
Setting regional caps to health expenditures can not resolve all problems, if they are not supported by up-to-date data on the movement of patients between regions. In Italy, where there is a permanent contrast between the rich industrialised north and the poor agrarian south, simply allotting more money to the south will not necessarily attract well-qualified workforce nor will it stop patients going north in search for health care. In addition, northern regions such as Lombardia and Bolzano are financially autonomous (in 2000, respectively, 81% and 82% of the health budget came from regional taxation), in contrast with southern regions as Calabria and Campania (where the equivalent figures were 24% and 28%, respectively) (20).
After more than 25 years of reform, Italy now has a Beveridge-type of health system, its deficit is under reasonable control, private health spending is around 25% ot total health cost (546 dollars out of 2,212 per capita) (6), decentralization is a reality as regions have more power than ever, and general practice has been established with a solid performance (the Italian primary care system had a score of 14 in the above-mentioned ranking, as it includes home visiting, medical records, etc.) (2,8,13,16).
a) doctors unemployment is a chronic problem, and many general practitioners have a very small patients list. In Italy, the optimum doctor to population ratio is considered to be one general practitioner per 1,000 patients (maximum 1,500 for full-time general practitioners). Part-time doctors, with a maximum of 500 patients, need supplementary sources of income,
b) there is direct access without referral to many specialists, as obstetricians, gynaecologists and ophthalmologists, and poor coordination between PHC and public specialists (mainly paid by fee-for-service, in policlinics and out-patient services),
c) paediatricians work in general practice as general practitioners for those under the age of 14,
d) nurses work in community teams, with only slight coordination with general practice,
e) receptionists and other staff personal are almost not existing in private premises, were general practitioners work mainly single handed,
f) community care (mainly devoted to preventive activities) is independent of general practice, having its own community teams. This means that general practitioners have mainly a personal care curative approach (in line with Osler’ paradigm),
g) in 1990, 40 % of the Italian population thought that “the health care system has so much wrong that we need to completely rebuild it” (highest per cent rejection rate in an international study, the Blendon report) (21). After the revision of the reform, in 1995, things seem to be going better (but again in 1996 a similar survey found 26% of Italians to be very dissatisfied with their health care system, the highest rejection rate in Europe) (13). In 2003 public satisfaction (in a scale form 0 top 10) has been 4, same score as in Greece, below the European average, but much better than in 1990 (15),
h) hospital beds are still in excess, as it is the case with the proportion of health personnel working in hospitals,
i) in 2001, no inequity in access to general practitioners was found, but the use of specialists showed a profile favouring the higher income users (12). Private insurance seems to be one of the factors contributing to this differential use. There are also systematic regional differences in specialists utilization, in favour of northern regions,
j) there seems to be a clear overuse of medicaments [in 2001, Italian pharmaceutical expenditure as a percentage of total health cost was 127 relative to the average 100 (17.6% of the total) in European OECD countries] (6), and
promote research or innovation. The Mario Negri Institute (Milan) has contributed to general practice development in Italy more than many universities.
II. b. Policy analysis of the Italian PCH case
The Italian case highlights the relevance of two practical difficulties when implementing a formal health system policy:
1) the lack of political continuity, which precludes policy proposals from being properly implemented. For example, many aims of the original 1978 reform where in the 1980s either not implemented or rapidly reversed by the new political coalition in power. And
2) the serious consequences of power imbalances and, within that context, of the fact that one of the main collective actors, the government authorities, proved unable to fulfill a critical obligation of its mandate, in this case controlling health expenditure. As usual, social insurance revenues were earmarked. But before the 1978 reform, the costs of the health care system was out of control because decision-making was based in a regulatory scheme with almost only two actors, insurers and professionals, as in any Bismarckian system with a very weak central government (50 governments in 50 years!). The government tried to change that, but somehow could not do so to its final consequences (16).
In a way, therefore, the history of the health system reform in Italy is the history of a struggle between central national government and the autonomous regional governments in a country with great differences in regional wealth. Again, Italy has had chronic uncontrolled health deficit for more than half a century, and the aim of controlling costs was driving most of the proposed reforms (20).
In 1978, the central government, using its formal policy power (and with the external support of ideas coming from WHO and the British experience), changed the health system for it to become a Beveridge one, giving PHC a central role and abolishing sickness funds [yet the government resisted WHO’s advice to establish health centres along the model in Finland, in view of the Italian culture of doctors as private entrepreneurs who had been contracting with sickness funds, and the very evidence of the British national health system, where doctors are independent contractors]. The pro-coordination reform introduced gate keeping, capitation and patient lists. The 1978 reform portfolio broke general practice in two: paediatricians for children up to 14 years, and quasi-general practitioners for the rest of the population. Both kinds of doctors had, and have, strong biological orientation.
Also, PHC was split in the Italian reform design into curative services (dominated by general practice, in which group practice does not exist as most physicians work in solo practice, with almost no other staff) and community services (dominated by nursing) (8,13,16).
broadened, but simultaneously supplementary fees for specific services had to be introduced.
Gate keeping was and still is weakly enforced in practice, as referral is not necessary for many specialists, and in many cases it is only a hierarchical, administratively formal measure (13, 22,). This is so because a strong hospital structure remains a leading characteristic of the Italian health system.
The reform could not fully attain its objectives because of the informal health policy power of professionals, and the local importance of hospitals for communities (as explained, local health units coordinate PHC with hospitals, and contract hospital services). In 1995, the updating of the reform shifted the power from local units to regions, and, in order to improve management, general managers replaced the elected committees in charge of local health units (which in turn merged to look for more power in contracting). But this had no specific impact on promoting PHC.
Before the Bassanini reform, central government had:
1) the source of financial power (taxation) but without any realistic possibility to cap the health budget,
2) weak knowledge and information power, and 3) very weak social support.
The regions enjoyed discretionary power on the expenditure side of the budget but lacked any significant power to raise revenues from their own sources, which created a serious accountability problem.
After the State took over the role of the old sickness funds, and in view of the cost explosion, the fiscal federalism has entailed new threats to PHC because regions are de-listing services and applying generalized patient co-payments. Co-payments decrease access to health services (some diagnostic and specialist services require 100% co-payments and some medicaments a 50% co-payment). They also favour the use of private specialists.
As a consequence of all the above, the considerable inter-regional heterogeneity in service provision that had always existed, has tended to increase over time in the form of distinct regional health services in the 2000s. These differences in wealth and service provision, by the way, might explain differences in specialists use.
In more technical terms, it is important to note that small patients lists generate the important professional disadvantage that general practitioners will not see the various presentation of disease with enough frequency. Practitioners may therefore have difficulties to maintain their skills in diagnosing and treating emergencies in dealing with rarer clinical case presentations, and in getting experience in handling common chronic illnesses.
As explained above, public dissatisfaction with the health care systems is noteworthy in Italy, the highest score in comparative international surveys in the 1990s (though improving slightly in the early 2000s) (15,21). Dissatisfaction might well be the consequence of poor system performance linked to permanent inter-governmental conflicts. The finding of the highest public dissatisfaction in the country with the highest physicians ratio per population is also highly revealing. Unemployment, small lists, low clinical quality, part-time hospital or private work, and weak gate keeping role seem to fuel in Italy the vicious circle of low social esteem, poor earnings, scarce research, low self respect and corruption (in some cases) in general practice.
III. PORTUGAL
III. a. PHC in Portugal as a case-study
With a population of a bit less than 11 millions, Portugal is a member of the former European Community (now EU) since 1986. In 2001, Portugal GDP per capita was 17,560 dollars. In general, Portugal’s level of income inequality is amongst the highest in Europe (together with that of the UK).
After a particularly hard fascist dictatorship of more than 40 years, which ended in 1974, the new democratic Constitution in Portugal (1976) established the right to the access of all citizens to “health promoting commodities”, of which health care is but one. In the late 1970s, population health indicators in Portugal were the worst amongst the western European countries and the government had strong social and political support for introducing reforms aimed at improving public services (4). Portugal (as the other Mediterranean countries presented in this paper) thus took a decided step to broaden the coverage of medical services and change its health care system financing from a predominantly social insurance base to a tax financed national health service (15,25,26).
Public coverage of health services was only 60% of the population in 1975. The National Health Service Law of 1979 stated that “access to the national health service is guaranteed for all citizens, independently of their income or social status” and public coverage became 100% in 1980.
The private health sector had always had an important role in Portugal. During the 1980s (when the first steps in shifting from a social insurance model to a tax-financed one were taking place), the country saw a continuous rise in the share of private health care expenditures. Years after the reform was launched, evidence shows that although the national health system claims to be universal, a number of occupational insurance schemes which tend to cover the better-off socio-economic groups remain in place (27). Implementation of the reform was difficult because the economic international general crisis of the 1970s, and the opposition of the professionals (trade unions and medical colleges) as well as of the sickness funds.
The persisting importance of the private sector is highlighted by the fact that after 25 years, the Portuguese health system relies heavily in private funding and provision for more than a quarter of the population. In 2001 private health spending was 31% of total health care costs (500 dollars out of the 1,613 per capita) (6). The health system has three financial sources: taxation (half the total), social insurance and private money (almost 40% of the total). Approximately, 10% of the population is covered by private insurance, mainly through group insurance provided by employers.
public employees’ sickness funds were privatised in parallel with the privatisation of many public enterprises. Ever since, civil servants with private insurance coverage are refunded and face substantial cost-sharing. In 1990, 1992 and 1993, new reforms were introduced aimed at increasing the efficiency of the system and decreasing public expenditures. The trend has always been in the sense of more privatisation, with an increased role for cost-sharing and private insurance (tax deductible) (25). Shared private and public work for doctors has been promoted.
In 1995, still a new change in the political sign of government, coupled with the evidence of limited resources in the private sector, slowed down the implementation of the privatisation reform and introduced some innovations in PHC (e.g., capitation, performance incentives and the Alpha Project promoting professional cooperatives) (25). Yet later on, legislation was not fully implemented and the latest change of government (again, of a different political ideology from the previous one) reversed the entire direction of the reform, in this case under the influence of the Maastrich Treaty and new “Euro” discipline.
Portuguese health care reform thus seems like a pendulum…, but the private sector has always managed to remain in its centrum.
As it also happens in Greece, Portuguese governance of PHC is centralized within a national health system. There are five regions in terms of planning, but decentralization of formal policy power, even when it was high in the political agenda, was never successful (25-27).
In 1946, the first social security law was passed in Portugal and before the early 1970s there was a “social security PHC”. The national PHC Directorate was reorganized in 1971 and again 1984, on both occasions following general WHO health policy recommendations and under advice from other countries.
The following landmark were important in developing general practice in Portugal:
1) a Norwegian-Portuguese collaboration, funded by the Norwegian Agency for International Development, which in 1977 helped to establish the Institute de Clínica Geral do Hospital de San Antonio in Porto [Institute of General Practice of northern Portugal], as well as to implement general practice in the district of Vila Real,
2) a British-Portuguese cooperation in 1979 which strongly influenced decision-makers through a seminal workshop on the future of PHC and through a study tour and its report, and
3) the National School of Public Health of Lisbon, which supported the necessary early academic and research activities (28).
In 1980 general practice became a medical specialty and three years later the Institute of General Practice of Southern Portugal was set up.
Before the 1978 reform, curative care was provided in social security medical clinics by physicians who worked part-time (two hours), while health centres were only involved in preventive care. A network of health centres was then developed in 1979. In the new health centres the above two functions were integrated; PHC teams are now responsible for addressing all health problems of the population in a limited geographical area. Professionals are public employees, paid by salary. General practitioners have a gate keeping role and a patient list. PHC is therefore based in a well developed network of health centres, staffed with multidisciplinary teams (mainly general practitioners, nurses and dentists), with a broad portfolio (from IUD and other contraception methods to antenatal, paediatric and community care) (8,13).
However, many problems remain in the Portuguese PHC:
a) Portugal has increased the proportion of GDP allocated to health services during the last decades, but PHC has been always under-funded. The proportion of the public health expenditure allocated to PHC has even fallen in relative terms,
b) general practitioners order many of the prescriptions and diagnostic tests on the advice of specialists. In fact, specialists do not order test directly in hospitals or private practice just to avoid increasing the expenses attributable to them!,
c) health centres are not properly equipped for carrying out quality diagnostic services, and for these procedures patients are usually referred to private settings. The relationship with private diagnostic centres (X-ray, laboratory and others) is settled by contracts, the so-called “conventions”. Clinical diagnostic tests are overused,
d) the above means a perennial under-utilization of equipment in public premises, either because of shortages in the supply of human resources, or laxity in administrative controls of providers who work simultaneously for the national health system and for the private sector,
e) doctor and nurses tend to work for the national health service in the morning and in private practice in the afternoon (although for general practitioners having additional private practice is becoming less usual),
f) there is a severe shortage of PHC personnel (both general practitioners and nurses). Portugal has in fact had to “import” Spanish general practitioners and African nurses (from former Portuguese colonies),
g) the gate keeping role of general practitioners is very weak. Formally, secondary care is only accessible after referral, but since people show a strong preference for hospital care, they very frequently use the hospital emergency departments as backdoor entry points (8,23),
general practitioner). Continuity of care and comprehensive care are almost restricted to chronic patients,
i) Portuguese health centres are huge in size and personnel, with an average of 80 professionals per health centre. In those circumstances, “health teamwork” is mainly just an ideal,
j) in 1995, the primary care score of Portugal in the above mentioned international study is of only 7 (maximum, 20), well below the average. Worse still, changes in scores over time have been negligible (6 in 1975, and 7 in 1985) (2),
k) there seems to be a serious medicament overuse [in 2001, pharmaceutical expenditures as percentage of total cost represented a 130 in relation to the European OECD countries’ average of 100 (17.58% of the total)] (6),
l) the population seems not to be happy with the current state of affairs. In 1996, 22% of the Portuguese population was very dissatisfied with the way health care is being run (14). In 2003, global satisfaction with the health system in Portugal was the lowest in Europe (3.3 in a scale form 0 to 10), worst even than in Hungary and Poland (15),
m) in Portugal the degree of “excess use” of specialist visits compared to their health needs by higher income groups is much larger than in other European countries (12), and
n) the powerful association of general practitioners has played an important role in supporting innovation in PHC but the results have only been mediocre due to their low relative power compared with that of other stakeholders. It scientific journal it is not included in Index Medicus.
In summary, and at the risk of oversimplifying, Portuguese public PHC is still weak and plays almost a complementary role respect to the private health sector. This often puts the public interest in the shadow of the private one. In many ways, PHC in Portugal is almost an invisible structure, eroded by low social esteem in the land of private provision and financing.
III. b. Policy analysis of the Portuguese PHC case
The Portuguese case-study mainly shows the difficulties of developing a PHC-led national health service in a country where,
1) ideology-led reforms are often incompletely implemented, due to managerial limitations, resistance to change and political discontinuity. Legislation is not seen as a tool, but as an end, and
The Portuguese society and governments have found insurmountable difficulties in building up a universal, free at the point of use PHC-led national health service. Public and professional dissatisfaction whit health care has not gathered enough informal policy power to re-build a national health system in full. Political instability (indeed linked with the handicaps in consensus building inherited from a fascist dictatorship) did not provide fertile ground for such a titanic endeavour. The reform has never ended because lack of clear objectives and continuous changes in politics and polities. In 1979, the reform had strong social support but strong opposition from professionals and insurers. After a few years, people became disappointed with democracy (which could not respond to excessive expectations), so the reform was changed (1985 to 1995) (23,25,26). And re-changed again (1995, 1999) because the influence of the Maastricht Treaty and the new Euro discipline.
In that context, external policy powers gave only slight support, as the British and Norwegian models were seen as strange and the knowledge base provided by WHO and WONCA was too much ideology-led.
The history of the Portuguese reform is also the history of the struggle to transform a health system (from Bismark into Beverdige) in a situation of extreme resource constraint, when private service provision played an important role. The private health sector has being always central in any turn of the reform process, and there is still too much overlap with the public health system (25-27).
The current combination of health system fragmentation and lack of decentralization (there are 5 regions with very limited decision-making power) has also proved deadly. There are many subsystems and schemes for which membership is based on professional or occupational activities parallel to the national health service (for example, for civil servants and some large companies’ staff). Public schemes thus coexist with a number of occupational non-voluntary insurance schemes which tend to cover the better-off socio-economic groups (8).
There currently is a tendency to decentralization in the 2000s, but the governance of PHC is a very centralized one and regions have not been given sufficient room to develop innovative approaches within clearly set objectives. A plan to decentralized such controls in the middle of the 1990s failed. Changes in the 1990s tried to improve satisfaction both of consumers and public health professionals, but they did not change the perception that higher quality services are provided by the private sector, particularly in high technology environments. Conventions (contracts with the private sector to provide specific services) are very common, and swallow a high proportion of total public health expenditures (23,26,27).
The national health service is dominant in the provision of hospital stays and general practitioner as well as child care. But it plays a minor role in specialist and dental consultation, as well in diagnostic services.
The role of cost-sharing in Portugal is also worth mentioning. The high out-of-pocket expenditures reflect the strength of the insurance funds but there is also evidence than national health service users face flat-rate co-payments for consultations and diagnostic tests as well, and pay in particular a large and rising proportion of the cost of drugs. A plan in the 1990s to vary the level of cost-sharing by income group could not be implemented allegedly because of administrative difficulties.
As already explained, a particular Portuguese problem is the increasing use of hospital emergency services. It is both an indicator of the strong preference for specialist care, and a way to bypass hospital waiting lists and the rigid appointment system in PHC (8,23). PHC is professionals’ commanded with little sensibility to patients’ demands and needs.
Portuguese PHC is weak (and will remain weak unless big changes are introduced!) because of its complementary role to private provision of care for diagnostic and specialist services. Lack of public diagnostic facilities has paved the way to a perverse use of PHC. On top of that, under-staffed health centres with a rigid appointment system restrict first-contact for acute care and increase the use of hospitals emergency services, thus closing a vicious circle in which PHC is not easily accessible, a real entry point to the system.
IV. SPAIN
V. a. PHC in Spain as a case-study
Spain has a population of 40 million. It is a member of the European Union (then the European Community) since 1986. Between 1960 and 1980 [and again from 1998 to present], Spain was one of the fastest growing economies among the developed countries. In 2001, per capita GDP in Spain was 21,294 dollars, and health spending as percentage of GDP was 7.5% (6).
After a hard fascist dictatorship of almost 40 years which ended in 1975, the new democratic Constitution was approved in 1978 and set up a semi-federal state. The Spanish people’s rights to health care and health protection are explicitly recognized in the Constitution. In 1977, one of the newly democratic elected government’s first initiatives was to create a Ministry of Health (“and Social Security”). Until then, most health care resources and health care services delivery were managed by the Social Security, within the Ministry of Labour (public health services and care of the very poor were in turn under the Ministry of the Interior and local authorities) (29).
The Spanish Social Security was a powerful quasi-autonomous public entity which at that time jointly managed the budget of medical care, cash benefits (pensions, unemployment, sickness leave payments, etc) and social services (elderly, handicapped, etc). In 1981 the Minister of Health was renamed as Minister of Health and Consumer Affairs, and Social Security lost its health budget while coming back to be a part of the Ministry of Labour.
In 1981, the failure of an attempted military coup d’état led to a strong social and political reaction against any remembrance of dictatorship. Following the political program of the Socialists in power from 1982 (until 1996), Spain began a wide program of social reforms. A General Health Law (National Health Care Act), passed in 1986, started the health system reform and regulated the national health system (29-31). The health system reform had five main explicit objectives:
1) extending universal coverage, from 90% in 1980 to 99% in 1990 (those not covered were the richest segments of the population, such as self-employed lawyers and others). By 1995 universalisation was practically completed (99.5%), although enrolment kept its original link to labour status and social security (Minister of Labour) until the present moment, instead of being done straight through the Ministry of Health and Consumer Affairs.
2) providing the basis for the transfer of the management of the public health system from the central government to the seventeen autonomous communities recognized by the new Constitution. Decision making was immediately transferred to four of them (Andalusia, Basque Country, Catalonia and Navarra) of which two had in fact started to enjoy that right before 1986. The whole decentralization process took more than a decade and finished only in 2002.
health services for the poor operated by provincial councils). Teaching hospital were attached to medical schools. The military was left with its own, separate health system.
4) providing support for the establishment of a nationwide network of primary care health centres, following the Finnish model promoted by WHO, and
5) changing the financing basis of the national health system. Until 1989, social security contributions represented about 75% of total public health financing, while transfers from tax revenues made up to the rest. In 1989 a formal transition from a public insurance-based model to a tax-based national health service model was launched and by the beginning of the 1990s, the proportion had been inverted. In 1999, public health care was solely (100%) funded through general taxes (30).
This has to be seen in a historical perspective. Since the beginning of the XXth century, Spanish employers and employees had developed hundreds of small sickness funds, very popular capitation-like, prospective payment arrangements (“igualas”) by which a flat monthly stipend was given to doctors or insurers according to the number of members of the family in exchange for the right to receive care in due time. The scheme became regulated by the Instituto Nacional de Previsión.
Before the Civil War (1936-1939), the National Parliament discussed a new law to develop a national sickness fund, which was never passed because the military coup d’état. After the Civil War, the fascist government established in 1942 a national mandatory sickness fund (SOE), primarily intended to provide curative services to industrial workers and their dependants and financed through social security contributions (29,32). Compulsory enrolment was gradually extended to other types of workers so that public coverage increased steadily throughout the years (54% of the population in 1960, 81% in 1975). The SOE surpluses were used mainly to subsidize other government industrial institutions.
In time, the SOE’s provision of solely curative services and its structural isolation from other health institutions became seen as important flaws of its organization. Nevertheless, the SOE experience forged in Spain an irreversible social agreement that access to health care is a right of the whole society, and one strongly valued by the population. The Spanish population learnt to value having a general practitioner, a fully equipped hospital network, and good continuity of freely provided care at the point of use (it has ever since become clear that any policies aimed at increasing financial obligations of the user when receiving the services are very unlikely to succeed) (29,30).
The public hospital network was supplemented in the 1980s and 1990s by hundreds of health centres built up in rural and urban areas (the firsts primary health care centres were established in 1984, before the National Health Care Act). In the 2000s, public hospitals account for almost 75% of all hospital beds. Health expenditure absorbed 7.4% of the GDP in 1997 (a percentage which was 31% higher than the 5.6% that it represented in 1980). The average annual growth of health care expenses in Spain between 1991 and 2001 has been 3.2% (6,30).
Health professionals (with the exception of ambulatory specialists and general practitioners) were, and still are, salaried public employees. Ambulatory specialists and general practitioners working for the SOE were paid under a pseudo-capitation system as the item of payment was the “social card”, which grouped the worker and his/her dependants. General practitioners were paid according to the number of social cards in their list, and had to devote two hours to office work and “the necessary time” for home visiting. They also had a gate-keeper role in relation to an identified group of specialists of a designated hospital to which each of them was linked for referrals. The system was, and is, very rigid, strictly pyramidal. Spaniards are allowed to select their general practitioner and paediatrician within certain geographical limitations (29,32).
The main characteristics of the Spanish PHC reform launched in the 1980s were:
1) organization and planning according to districts of around between 40,000 and 250,000 population, which included sectors of between 5,000 and 25,000 population. Each sector has one health care centre, staffed with general practitioners (one per 2,000 population), paediatricians (one per 1,000 children), nurses (one per doctor) and a variable number of midwives, social workers and ancillary staff. The health centre is explicitly requested to be the main management unit coordinating curative, treatment, preventive and promotion, as well as community care activities,
2) full time employment (doctors were requested to shift from 18 hours per week in the old clinics to 40 per week in the new health centres); however, physicians could keep the privilege to practice privately after their public service obligations,
3) paediatricians (who had been so far caring of those under 7 years) expanded their population until those under 14 years,
4) health professionals were integrated in “primary care teams” with broader portfolio of curative and preventive activities [teaching and research activities are, respectively, explicitly and implicitly included]. Nurses work on their own, mainly taking care of chronic patients, home visiting and preventive activities following guidelines provided by the health centre. For daily clinical work, the “minimum team” is a doctor and a nurse who take care of a defined population (patient list),
5) salaried doctors (general practitioners and paediatricians), with a capitation surplus according to the size of their personal patient list, have a gate-keeper role. Nurses are salaried and receive an allowance in proportion of the total population of the health centre,
7) a construction programme of new health centres (purposefully built, fully equipped) to provide quality PHC.
In 1978, Family and Community Medicine was legally recognized as a postgraduate specialism of general medicine, with an appropriate vocational training. However, training was mostly provided by the government outside the universities and the first chair of general practice was established (in Barcelona) only in 2002 (a “Novartis” chair). The Association of Family Physicians supported the PHC reform, and has always shown a strong commitment to promote prevention and research activities, with a scientific journal included in Index Medicus (4).
After the initial changes, the Spanish health system reform has undergone frequent adjustments mostly addressing organizational issues (as first recommended by the Abril
Report, published in 1991) which have invariably followed a supply-side approach aimed at keeping costs within reach (23,30). Regional allocation of resources is mainly based on population and has not worked particularly well in controlling the health budget. The accumulated health system debt has had to be recognized and specifically funded on several occasions. The Maastricht Treaty and the new “Euro” financial discipline forced further changes in the reform, to improve macro and micro-efficiency, and to improve patient’ satisfaction. In any case, the solution has been a deepening of fiscal decentralization but even in 2004, after the full decentralization of planning, management and budgeting, there is concern with the systematic transcending of the health budget.
From 1994, PHC teams have a performance annual payment according to some process indicators (e.g., percentage of diabetic patients with a normal level of blood hemoglobin A1c) and control of pharmaceutical expenditures (medicaments absorb more than 20% of total public health expenditure; in spite of efforts to reduce pharmaceuticals’ expenditures, success has been rather scarce). The objectives of this collective incentive have been formulated as
1) extending the portfolio of PHC (for example, antenatal care), 2) increasing inter-professional cooperation,
3) improving the quality and controlling the costs of prescriptions, 4) implementing a quality assurance program, and
5) reinforcing the role of the general practitioner as gatekeeper (4).
Since 1995 also there is an explicit definition of the package of benefits covered by the public sector. Excluded services are psychoanalysis, surgery to change sex (which has recently been included in Andalusia), spa treatments and elective aesthetic surgery. Exclusions in practice also include institutional mental care, dental services for adults and some prostheses, such as spectacles. The only existing cost-sharing in Spain is for medications, for which the average patient has to pay around 40% of the cost, except for life-saving products (for example, insulin). Pensioners and their dependants are excluded from paying (29-32).
providing an alternative modality of care. In 2004 some 7.9% of the population had private health coverage through voluntary insurance (whereas the privately insured in big cities is some 20–25% of the population of Madrid and Barcelona). Employer-purchased health care insurance schemes, according to survey data, covered 3.8% of the Spanish population in 2004. Jointly considering all categories of private insurance (purely voluntary and employer-purchased insurance for a total of 11.7% of the population) with the before mentioned (publicly funded) civil servants’ mutual funds, the percentage of the Spanish population covered by private insurance is around 15%. The population with double insurance coverage frequently uses the public coverage for hospitalisation and private insurance for specialists’ consultations. The private sector is important, but the size of the market has remained stable over the past decades (in clear contrast with the situation in other Mediterranean countries). A recent policy promoting collective private insurance through employers (by considering the corresponding contributions as income-exempt for the wage earner and deductible expenses for the employer) has been issued but its consequences have not yet been evaluated (30).
In addition, public employees and their dependants (almost two millions in total) have a special insurance scheme. It is a voucher system through which the public employer (national and local governments) pays a non-risk adjusted capitation payment to the private insurance plan of the civil servant’s choice. The option can be exercised on annual bases. Around 90% of public employees currently opt for private coverage.
Expenditure in social care only amounts to 1% of the GDP in Spain, a considerably small figure for western European standards. Historically, health care benefits in Spain do not include social and community care, which is partly in the hands of the Ministry of Labour and Social Affairs and partly decentralized to autonomous communities. A Royal Decree in 1995 allowed Regions (Autonomous Communities) to incorporate health activities and services provided that they would use their own resources. The Cohesion and Quality Act of 2003 stipulated the following services to be provided by the National Health System in addition to those contemplated in 1995: public health, primary and secondary health and social care, emergency, pharmaceuticals, ortoprosthesis, nutrition services and transport in relation to health services (transport sanitary). It also specified which services should be agreed upon in the heart of the Inter-Territorial Council thus overcoming lack of precision in the terminology for some time which had hindered a clarification of the difference between services and techniques or procedures.
Human resources planning also received attention during the reform. There has historically been a severe shortage of nursing personnel which refers mainly to hospital (PHC nurses are better paid and have more professional autonomy) combined with an oversupply of doctors. A nationwide numerus clausus for new medical students was made mandatory in 1979. In 1983, more than 10,000 new physicians graduated, the highest figure in the history of the country. In fact, and as already mentioned, Spain is “exporting” in the 2000s general practitioners and pharmacists to European countries like Portugal, Sweden and the UK. Specialists initially resisted the reform but as changes in hospital care were never at once nor deep, their resistance soon decayed.
in transition, and 28% of the population replied to the Blendon Report that “our health system has so much wrong with it that it needs to be completely rebuilt” (33). In 1996, however, only 8.2 % of the population was “very dissatisfied with the way health care runs” (14). In 2003, the health care system obtained 5.4 points (in a scale from 0 to 10) in an international customer satisfaction survey (15).
In summary, population coverage is now de facto 100%. In PHC, electronic medical records are almost universal. Research is well developed in PHC, supported by general practitioners associations and funded by national and regional agencies. Total health care budget has increased until 7.4 of the GDP and although Spain lacks a definitive model of health system financing, due to the complex balances between the centre and the autonomous regions, health care expenses are under much more control. Private spending is 29% of the total health spending (457 out of1,600 dollars per capita) (6). Nevertheless, the Spanish PHC still confronts some serious problems:
a) the total amount of PHC budget has increased, but the percentage remains constant (around 16% of total health spending), which raises doubts about the priority given to PHC versus other care modalities,
b) the referral system is weak and frequently the gate-keeper function is mostly a formal role. The health system is in many ways specialists driven. Coordination between levels is difficult or not existing,
c) the rigidity of the referral system (general practitioners cannot select neither the specialist, nor the hospital) and long waiting list for specialist care, constitute a powerful incentive for for patients to leave the public system and obtain direct access to specialists through additional insurance or direct payment,
d) satisfaction with PHC is comparatively low, and there is a danger of developing a two tier system (public PHC for the elderly, the poor and the immigrants, and private insurance for the better-off),
e) although additional private practice is unusual for general practitioners (except in Catalonia, with an historically important private sector), it is rather frequent for paediatricians and specialists,
f) paediatricians work in general practice as general practitioners for those under 14 years, and there are pressures to increase the age to 18, which goes against the role of general practitioners as responsible for the care of the person throughout his/her life span,
g/ efforts to reduce pharmaceutical expenditures have not succeeded. Medications are responsible for an unduly high fraction (more than 20%) of total public health expenditures. Worse, there is not only a problem of quantity, but also of the quality of those expenditures (34),
