The WHO Barcelona Office for Health Systems Financing has promoted the first exhaustive analysis of financial protection in Spain, led by a team of national experts. The report entitled Can people afford to pay for Health Care? New evidence on financial protection in Spain jointly analyzes microdata from the INE Family Budget Surveys between 2006 and 2019 (the latest data available at the time of publication) and data on unmet needs for health services provided by the European Union Statistics on Income and Living Conditions (EU-SILC).
Financial protection, what is it and why is it important?
Financial protection is a paramount element of universal health coverage and the performance of health systems and is measured by two indicators: catastrophic health spending, which occur when out-of-pocket payments for health care exceed 40% of the household's ability to pay once it has met its basic needs for shelter, food and supplies, and impoverishing health spending, which occur when out-of-pocket payments push households below the poverty line or they become even poorer if they were already below that threshold. The lack of financial protection can undermine access to health care, and health status, deepen poverty and exacerbate health and socioeconomic inequalities. People experience financial difficulties when out-of-pocket payments—formal payments (copayments) and informal payments made at the time of using any health good or service—are high relative to a household's ability to pay for health care.
How many people experience financial hardship in Spain and what services cause it?
According to the latest data available in the report, nearly 300,000 households have catastrophic health expenses in Spain. Of these, some 200,000 households belong to the poorest quintile. These households are forced to decide between paying for access to health services or meeting other essential payments such as rent, heating or food. In addition, about 150,000 households are made poorer, or poorer still, as a result of out-of-pocket (or out-of-pocket) payments for health care.
The services responsible for these financial difficulties are fundamentally dental care and optical care in all homes. The first is covered to a very limited extent by the National Health System (SNS) and the second (glasses, contact lenses) is excluded from its coverage. In the poorest households, medicines (subject to co-payments) also play an important role in generating financial difficulties.
Spain in the European context
Despite having worsened during the economic crisis, the incidence of catastrophic health spending in Spain is one of the lowest in Europe. This is explained by the strengths shown by the SNS coverage policies: coverage of practically the entire population based on residence; a fairly broad portfolio of health services with minimal variations between autonomous communities; Limited copays for prescription drugs and ortho-prosthetic devices, and different protection mechanisms for these copays (reduced copays and cap per prescription for drugs for chronic diseases, exemptions from co-payments for disadvantaged groups, and monthly income-based caps for pensioners).
Impact of the economic crisis and lessons learned
The economic crisis had a detrimental effect on the financial protection of Spanish households and modified the profile of households with catastrophic health spending. Although the incidence of catastrophic spending began to decline in 2016, in 2019 it was still above pre-crisis levels. Catastrophic spending increased between 2008 and 2015, reflecting a decline in the ability of households (especially the poorest) to pay for health care. The austerity policies implemented between 2012 and 2014 contributed to worsening this situation. Public health spending was cut, access to the SNS was limited for undocumented migrants and co-payments for prescription drugs were introduced for pensioners or co-payments were increased in the case of the active population and children. During the crisis, households with catastrophic spending went from being headed by pensioners to being headed by people of working age, couples with children, and unemployed people. The protective effect of the pension system and the monthly caps established in the copayment scheme for pensioners (which do not exist for the active population and children) explain this situation.
Since 2018, various measures have been taken to strengthen financial protection in Spain. In 2018, the residence was reestablished as a criterion for SNS coverage, which formally meant that undocumented migrants regained full coverage. In 2021, new co-payment exemptions for the pharmaceutical benefit were established for various disadvantaged groups, including recipients of the minimum vital income, low-income pensioners and children with moderate and severe disabilities.
Pending challenges and recommendations to overcome them
The draft Law on Equity, Universality and Cohesion approved by the Spanish Government in November is a necessary step, but insufficient to substantially reduce financial difficulties and unmet health needs in Spain. The draft bill introduces new exemptions to healthcare co-payments, extending those approved in 2021 for pharmaceutical benefits to the ortho-prosthetic benefit. It also contemplates establishing the necessary guarantees to avoid the introduction of new co-payments. However, the current co-payment scheme for medications and ortho-prosthetic benefits does not offer sufficient guarantees of protection to the poorest households, especially those headed by people of working age, so it is necessary to establish income-related caps for the general working population. In addition, it is essential to address the main coverage gaps of the National Health System by expanding the coverage of dental and optical care services.
The persistent problem of waiting lists for secondary care and certain surgeries, which worsened during the economic crisis and has been exacerbated by the current pandemic, needs urgent attention. Waiting lists represent a significant barrier to accessing health services and push people to pay out of pocket for services included in the NHS benefit package. In addition, they are behind the gradual increase in the contracting of voluntary health insurance and, since the contracting of voluntary health insurance increases with the level of income, they contribute to increasing inequalities in access to health care.
Finally, for population coverage in Spain to be truly universal, the administrative obstacles faced by undocumented migrants must be eliminated (legal loopholes and delays for social services to authorize access), foreigners legally regrouped with family members residing in Spain and asylum seekers (delays in the process of recognition as asylum seekers).
Spain is in an excellent position to continue leading the way toward universal health coverage in Europe, but it needs to act fast and effectively without becoming complacent. The recommendations included in the report would contribute to strengthening resilient health coverage, one that guarantees that people keep health coverage when their standard of living or their health declines and that entitles them to greater protection when they find themselves in situations of socioeconomic vulnerability.
José Cerezo Cerezo is a health policy analyst (consultant) at the WHO Barcelona Office for Health Systems Financing and technical editor of the report Can people afford to pay for health care? New evidence of financial protection in Spain.
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