Healthcare Europa interviews Dr Arturo Alvarez, consultant at Técnicas de Salud, the leading Spanish healthcare industry consultancy.

HCE: Essentially the Spanish system is based on a state-funded NHS as in the UK as opposed to the more mixed insurance systems in France and Germany.

AA: Yes but there are some very important differences. Firstly 17 autonomous regions actually have responsibility for delivering healthcare and have a great deal of freedoms. So certain regions, such as Catalonia, Valencia and Madrid, have involved the private sector and the not-for profit sectors far more than others.

In Catalonia two thirds of secondary healthcare is delivered by consortia between the public and the not for profit sectors, such as the Red Cross and the Catholic Church. In Andalucía, there is one consortium run by a Catholic religious order. In addition, since the early 1990s, Catalonia has allowed the contracting of the provision of primary care services with private companies and cooperatives of health professionals– what is known as Entidades de Base Asociativas (EBAs).

Various autonomous communities have made use of Private Finance Initiative (PFI) schemes to build new hospitals or reform existing ones. In Madrid, 7 new hospitals have been built or are being built as PFIs. Castilla y León is using this scheme to build a hospital in Burgos and the autonomous community of Balearics is doing the same in Son Dureta.

Valencia and Madrid have gone one step further to build and run hospitals under the form of administrative concessions (concesiones administrativas) such as the Hospital de la Ribera in Alzira and the Hospital Infanta Elena in Valdemoro in Madrid. These two administrative concessions are PFIs by which a private company (or group of companies) builds and manages a public hospital, in which the majority of patients treated are public patients. Very importantly, the management includes clinical and non-clinical services as well.

Finally, many autonomous communities have been outsourcing day surgery and diagnostics.


HCE: So what are the ways the two sectors work together?

AA: To build and run public hospitals, there are three principal forms –consortia, PFIs and administrative concessions. Now, regarding primary care, mainly the EBAs used in Catalonia.

HCE: There are several famous experiments involving administrative concessions aren’t there like Alzira?

AA: Yes. Alzira was the first administrative concession established in Spain, by the autonomous government of Valencia, generating a huge discussion in the Spanish health community. The Alzira model is also interesting because it now covers primary and specialized care. The hospital is run by a group of private companies led by the health insurer Adeslas (who is the biggest shareholder).
After Alzira, other four administrative concessions have been established in the autonomous community of Valencia: the Hospital de Torrevieja; the Hospital Marina Alta de Denia; the Hospital de Manises; and the Hospital de Elche.

In all these five concessions, one of the shareholders is a company formed by two Spanish banks – in Torrevieja and Elche being the biggest shareholder. The other shareholders are private health insurers such as Adeslas (as mentioned above, in Alzira) as well as Asisa, DKV and Sanitas. And, in Madrid, the Hospital Infanta Elena in Valdemoro that I mentioned before is run by Capio.

While PFIs and administrative concessions are all different forms of private-public partnerships, there have also been other hospital reforms over the last decade aimed to grant more autonomy to hospitals, but which do not include the participation of the private sector. The three main types are the “Empresa Pública Sanitaria”, the “Fundación Pública Sanitaria” and the “Fundación”.

There is a sort of continuum in terms of self-governance, from the more top-down managed “Empresa Pública Sanitaria” to the allegedly more independent “Fundación”. The most famous example of the latter is Alcorcón, south of Madrid. It is known in England because the British secretary of state Alan Milburn came to Spain in 2001 to sign a contract to take nurses to the UK and was shown this hospital Fundación Alcorcón. He was so impressed that he took the idea back to the UK and this was the origin of the UK foundation hospital movement. What is really amusing is that the Spanish originally copied the idea from Margaret Thatcher, the hate figure of Milburn’s Labour government!

Actually, there used to be more foundation hospitals in Spain. A national and socialist coalition in Galicia took power last year and since July 2007 have reintegrated four foundation hospitals into the centralised model.

HCE: And I guess we then have private/private work where patients decide to use the private sector, because they are privately insured, or because they are willing to pay themselves.

AA: Well, the public health system covers around 95% of the population and is free at the point of use. Therefore, it´s only 5% of the population who only use the private sector. Most of these people (around 4.5%) are civil servants or members of the armed forces or other privileged groups who are obliged to contribute to private health insurance schemes, and can choose every year between using the public health service or using private healthcare providers (the vast majority of them prefer to use the private sector unless they have a serious condition or need special treatment). Another 10% of the population is covered by the public health system but has also a private health insurance.

Overall, thus, the private sector provides services to 15% of the population. In fact, in my opinion, Spain is certainly not ready for wholesale privatisation. I’d say it was a lot less politically acceptable than in the UK. Madrid is being very careful to avoid the impression that it favours wholesale privatisation. People are proud of the state sector Yes, there has been an increase in private provision of healthcare but I expect to see more outsourcing rather than any radical governance changes.

HCE: I guess you also have the diagnostics sector where there are a lot of private players in imaging and laboratories aren’t there. I’m told the Spanish lab sector is far more effective than its French counterpart which is hedged around with regulator restrictions.

But you would argue that in general the space for the private sector is quite limited?

AA: Yes and the private sector is aware of this. So it is trying hard to emphasise that there is no conflict between the two sectors. They are saying that the private sector is not here to compete or poach but to provide a public service. Emphasis is on the social goals and benefits they provide. There is a big emphasis on new technology as well.

HCE: So Spain is a real patchwork quilt?

AA: Very much so, yes. A private operator might operate a concession in Madrid, outsource in another region and run a completely private hospital somewhere else.