Revenues of the Spanish public administration have dropped sharply due to the crisis, and not surprisingly experts have turned their attention to one of the biggest components of the budget: the public health system. The regional governments, the chief suppliers of health services, which take up some 35 percent of their budgets, are particularly affected by a shortfall that increases monthly, generating a debate strewn with booby-traps. The first of these concerns the sustainability of the whole system. Health is a pillar of the welfare state. The Spanish system in particular, universal and free of charge, is equitable, of good quality and reasonably efficient, though there is room for improvement.
The system is highly valued by the public, and is cheap. In relation to GDP (6.1 percent) it is well below the average for the OECD and, of course, for the US and the major EU countries. The main causes of deficit are the ageing of the population, shortcomings in new technologies and abuses in the utilization of resources; but also, and most notably, low budget levels, which still have some way to go before reaching the European average. Former prime minister Felipe González has lately proposed that this budget be raised, while eliminating certain questionably useful institutions such as the offices of the central government's representatives in the provinces. As was to be expected, certain regional politicians have welcomed the first proposal, while turning a deaf ear to the second. The provincial offices, like the regional television networks, are organs of power and costly ones.
However, most of the regional governments are now introducing rationalization measures that are bearing fruit. Among these are an incipient centralization of purchases and a reduction of the pharmaceutical bill, imposing price cuts and subsidizing only the cheapest ones. But much is still pending, such as the sale of pharmaceuticals in single doses, and other more complex measures, such as that of motivating doctors by increasing the variable part of their wages, or a reorganization of services, a difficult task due to labor union reluctance. Harder to understand is the closure of health centers (at least 40 this summer) in Catalonia, the threatened reduction of hospital restaurant services in the Madrid region, or the failure to replace absent personnel in Andalusia. Such moves are even more absurd when accompanied by tax cuts, or promises thereof, as in several regions.
Raising the public health budget, as González has proposed, could be paid for by taxes, but also by co-payment. Italy is about to introduce a tough co-payment plan, within its deficit-reduction package, which may leave the most needy outside the system. Yet co-payment may be feasible if it helps to safeguard the public system without compromising its equity. For example, token (but highly dissuasive) payments might reduce Spain's per-capita rate of visits to the doctor, which is the highest in Europe. Facts such as this must be kept in sight as the process of rationalization continues.