Good health is highly valued and is recognised as a fundamental right in the Spanish Constitution, which establishes that the public authorities are responsible for protecting citizens’ health through the measures and services required to achieve this. In addition, health is central to three of the 20 basic principles of the European Pillar of Social Rights, approved in 2017. These principles enshrine the right of every person to “timely access to affordable, preventive and curative health care of good quality.” Moreover, they explicitly recognise the right of people with disabilities to the income support and services they need to ensure their full participation in society and the economy, as well as the right to “affordable long-term care services of good quality, in particular home-care and communitybased services.”
Universal access, satisfactory care throughout people’s lives (from birth to death) and services of good quality feature in every statement regarding the right to good health. In addition, these statements call for care to be affordable for all citizens. Healthcare and long-term care are both services that can cost far more than affected people are able to pay. Consequently, it is important to guarantee that a lack of financial wherewithal does not represent a barrier to entry to the system by using effective financial protection mechanisms. Nor should other factors such as gender, age or place of residence constitute barriers.
There are many aspects and challenges involved in protecting good health, understood here to mean a state of physical, mental and social wellbeing rather than an absence of illness or disease (WHO, 1948). In this report, we analyse the basic challenges from the perspective of society’s needs using a set of indicators that are useful for evaluating policies and their impact. This analysis is structured around the following challenges:
1. To maintain and improve the population’s state of physical and mental health: Individuals’ state of health is dependent on numerous causes and on the structure of the population. In an ageing society, health problems change and the way they are tackled must be adapted. Health policies need to foster improvements in the population’s levels of physical and mental health by means of satisfactory preventive and curative measures suited to the demographic needs and structures of the time.
2. To promote healthy lifestyles that will help to prevent disease: The incidence of many diseases and health problems can be reduced if we adopt healthier lifestyles. Diet, physical exercise, alcohol consumption, smoking and drugs are major issues on which action can be taken. Monitoring the prevalence and evolution of the main risk factors helps to detect areas where it may be necessary to step up public health policies.
3. To guarantee access to healthcare. Equitable access to healthcare is a basic social right in a developed country. To ensure that there is fair access, countries must have a healthcare system that can provide the required care to the people who need it, regardless of their personal circumstances.
4. To guarantee access to dependency care: Increased life expectancy has made it necessary to accept long-term care for dependent people as a new social right. Universal access for all on an equal footing must be guaranteed by the public authorities to ensure that no-one is excluded from this care simply because they cannot afford to pay for it or because there is a shortfall in adequate service provision (day centres, homes, etc.).
1. Executive summary
The most important
- Now that the public dependency care system is operating, there has been an improvement in the degree to which the social need for long-term care in Spain is being met. However, there is still an unmet demand for care and inadequate professionalisation among those providing the care.
- Even though people are taking more exercise and are eating more fruit and vegetables, the level of obesity has risen in recent years and is a serious public health problem in society today. Binge drinking, a phenomenon associated particularly with young people, has increased dramatically in recent years.
- The health system in Spain is universal, meaning that almost nobody is unable to see a doctor for reasons of poverty, distance or because they cannot get an appointment. However, a certain percentage of low-income families have difficulties in areas such as purchasing medication or dental care, and they sometimes incur expenses that are excessive in relation to their ability to pay. In other instances, the barriers to access are long waiting lists, an aspect that worsened during the economic crisis.
- People’s perception of their state of health has improved considerably in recent years. The percentage of people whose poor health limited their ability to engage in daily activities has fallen and there are fewer senior citizens who believe they are severely limited. The percentage of chronically ill patients diagnosed with hypertension has also dropped, though other conditions such as diabetes, high cholesterol, anxiety, depression and other mental health disorders are on the rise. In addition, the percentage of chronically ill people at cardiovascular risk also fell by one percentage point between 2006 and 2017.
The most importante
- The percentage of adults who declare they are in poor health or suffer from a problem that makes it difficult to perform activities of daily living is lower in Spain than the European Union average, above all in 2017. This comparison has been arrived at by adjusting the differences in the age structures of the various countries; consequently the results are not affected by differing degrees of demographic ageing.
- There are also comparatively fewer people aged over 65 who state they suffer from severe limitations in their everyday lives due to health problems. Moreover, there was an evident improvement in this parameter between 2009 and 2017. Even though this information is not based on objective assessments of the degree of dependency or disability, this indicator can provide an estimate of the demand for long-term care among senior citizens.
- Almost nobody in Spain declares they were unable to visit a doctor because it was too expensive, too far to travel or due to a long waiting list in the previous year. As a result, Spain ranked top in this indicator in 2017. With regard to visits to dentists, inaccessibility is slightly higher than the European average and the reasons given are almost always of a financial nature.
1. People’s state of good health
One of the most important goals of efforts to meet society’s needs in any country is to improve the population’s state of health. The set of data concerning the state of health of the Spanish population show that there has been a considerable improvement in recent years. There has also been a reduction in the percentage of people whose poor health limits their ability to pursue daily activities and in the percentage of the chronically ill diagnosed with hypertension. There has, however, been a rise in other diseases such as diabetes and high cholesterol as well as anxiety, depression and other mental disorders.
2. Healthier lifestyles
Mention must also be made of the improvements in the promotion of healthy lifestyles. In recent years, there has been a reduction in the number of people living purely sedentary lives, as well as an increase in the proportion of the population following a healthy diet, a key factor in preventing chronic illnesses and other health problems. There has, however, been a rise in the incidence of obesity, with its prevalence among children being particularly worrying due to its short-term and long-term impact on their health, and because of the associated substantial direct and indirect costs to the health system.
3. Few barriers to access to the health system
Of all the countries in Europe, Spain is the one that has the best access to the health system; in other words, it is the country where the population has the fewest problems in accessing health services. Universal coverage means that hardly anyone has to forego seeing their doctor due to a lack of money or because of the distance or because they cannot get an appointment. Even so, this coverage does not guarantee effective access to the package of services necessary to safeguard people’s health. Difficulties of access in some aspects, such as visits to the dentist or the purchase of medication, are higher than the European average, essentially because of financial issues. Lowincome families sometimes find themselves facing health-related costs that are excessive in relation to their ability to pay. These problems doubled during the economic crisis due to the combined impact of the fall in income and the medication copayment reform. In other instances, barriers to access are due to waiting lists, a problem that also worsened during the recession.
4. Increasing dependency care
The implementation of the public dependency care system has improved the degree to which society’s need for long-term care is met. Nevertheless, there still exists an unmet need for care, as well as insufficient professionalisation among carers. One of the problems in the System for Autonomy and Dependency Care (SAAD) has been the lengthy delays in the provision of services and benefits. In any event, even though the percentage of dependent senior citizens has fallen slightly in recent years, the ageing of the population inevitably means there will have to be an increase in cover and in the amount of care provided.
5. Doing better than Europe
The level of satisfaction connected with some of the challenges that affect society’s health related needs is, in general, higher in Spain than in the rest of Europe. Objective indicators such as life expectancy and the mortality and morbidity rates, but also citizens’ own perceptions, reflect the fact that the population in Spain is in a better state of health than the populations of most other European countries. There are also comparatively fewer people over the age of 65 who declare that they suffer severe limitations in their everyday lives due to health problems, an indicator in which there has, moreover, been an improvement in the last ten years.
6. Worse than Europe
The situation with regard to healthy lifestyle habits is not as positive, as Spain occupies a midtable position in Europe. The Spanish diet is healthier, but there is a higher consumption of illegal drugs such as cocaine and cannabis. Spain and other countries in Europe are very alike with regard to the percentage of people who smoke every day or who consume alcohol, but it is behind in terms of the physical activities deemed beneficial to health, the incidence of obesity and young people’s use of illegal drugs.
7. Trends in health-related spending
The levels of expenditure on health in recent years have been detrimentally affected by the strains caused by the combination of the universal nature of the system, the growing demand for healthcare and the budgetary restrictions affecting all public spending policies. Spending per capita rose in the years leading up to the economic crisis, at which time this trend came to an end. Since the economy began to recover, the amount of spending per capita has risen again, though at a slower pace than prior to the recession. Despite the upward trend over the long term, Spain continues to occupy a mid-table position among European countries, both as regards per capita spending and as a percentage of GDP.
8. Expenditure on medication and copayment
A significant proportion of healthcare spending in Spain goes towards expenditure on pharmaceutical products, which has traditionally been a considerable burden and is higher than the European average within all public healthcare spending. Until recently, the amount of this spending that patients covered out of their own pocket was relatively small, in part due to the exemption of incapacity benefit recipients and pensioners, who are responsible for a high and growing proportion of the consumption of medication. The introduction of the copayment system, however, increased the percentage of the cost covered by users, particularly in the case of incapacity benefit recipients and pensioners. This change has led to an increase in average spending on pharmaceutical products per household, with medication now absorbing a larger proportion of family income in households in the middle-to-low income brackets.
9. Efficiency in healthcare spending
Despite the reduction in the financial resources allocated to the public health system, Spain comes out as one of the top countries in a ranking of the effectiveness of this spending. The indicators on unnecessarily early and medically preventable deaths failed to improve during the economic crisis but even so they remained lower than those of other countries with higher spending. However, this greater efficiency and the tendency to improve seem not to be perceived by the public, who believe that healthcare services have deteriorated in most of the main areas.
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