The situation in Spain
1. First challenge:
To maintain and improve people’s state of health
The primary challenge in the health field is to ensure that the population is in the best possible health. Good health depends on numerous individual and collective factors (genes, lifestyles, salubriousness of the environment, medical advances, etc.). There are also factors associated with the human lifecycle that strongly influence the incidence of certain diseases. The structure of the population (whether the population is younger or older) influences the state of health. Even though old age and illness do not always go hand in hand, people’s state of health tends to decline as they age. Consequently, in assessments of advances or setbacks in this challenge, it is advisable to use standardised or age-adjusted indicators in order to eliminate the composition effects caused solely by the change in the age structure of the population. To circumvent this problem, the indicators chosen to represent this challenge have been age adjusted. Using a common age structure makes it easier to compare the rates and percentages of different population groups (different age groups). The baseline population taken is the European Standard Population (Waterhouse et al., 1976). The only exception relates to severe limitations among senior citizens, as this indicator by definition concerns only the population group aged 65 and over.
One of the indicators customarily used in relation to people’s state of health is self-assessment. In the last ten years, people’s perception of their state of health has improved considerably.
The data show that between 2006 and 2017 there was a one percentage point drop in the number of chronically ill people at risk of cardiovascular disease. Even so, it should be noted that chronic illnesses that are factors in cardiovascular risk affect a large part of the population: one in four people suffer from hypertension, high cholesterol or diabetes. There has been a downward trend among those suffering from high blood pressure, but not those suffering from diabetes or high cholesterol, as the percentage of people with these problems has risen by around 13% since 2006. Diabetes is a particularly serious problem, as this upward surge affects not only older people but also children (aged under 14), among whom the percentage stands at 0.1%, a figure that is low but which nevertheless doubled between 2006 and 2017.
The percentage of people with health problems that limit their daily activity also fell between 2006 and 2017, though the reduction is concentrated in 2017, so this trend will need to be confirmed by more data in the future. In previous years, this indicator remained relatively stable at around a fifth of the adult population. The percentage of older people who declared they faced serious limitations in performing activities of daily living also fell noticeably in 2017. This is important because if this trend continues, it implies greater independence and improved quality of life for the demographic group that will increase the most in the coming years.
According to the data collected in the National Health Surveys and the European Health Surveys in Spain between 2006 and 2012, the percentage of adults aged 15 and over who suffer from and have been diagnosed with depression, anxiety or other mental health problem has dropped by more than two points. Nevertheless, this downward trend came to a halt in 2014, with a higher incidence of mental health problems recorded in 2017 than in 2009. These mental health problems, particularly depression, are more frequently diagnosed among women than men.
2. Second challenge:
To promote healthy lifestyles
There are many scientific studies that demonstrate the positive association between regular moderate physical exercise and a reduced risk of suffering from cardiovascular diseases, hypertension, type 2 diabetes, mental health problems (depression or anxiety) and obesity, among other chronic illnesses. Between 2012 and 2017, the percentage of the population that took no exercise in their free time fell by almost seven percentage points. Sedentary behaviour is more common among women than men, particularly in the youngest (aged 15 to 34) and oldest (aged over 80) age groups.
Just as regular physical exercise helps to reduce the risk of certain diseases, so eating a healthy diet is key to preventing a large number of chronic illnesses and other health problems. Regular consumption (on a daily basis) of fruit and vegetables is a good indicator for studying this healthy lifestyle habit among the population. The data in the National Health Survey and the European Health Survey in Spain show that the percentage of the population who do not eat sufficient fruit and vegetables has fallen since 2009. Nevertheless, 29% of the population aged 15 and over continued to consume an inadequate amount of fruit and vegetables in 2017. The highest percentages of the population eating an unhealthy diet are concentrated among the youngest age groups.
Clinical studies also indicate that obesity is a major risk factor for cardiovascular diseases and other chronic illnesses and health problems, among them hypertension, high cholesterol and diabetes. The data collected in health surveys show there is a high prevalence of obesity in Spain and that there has been an upward trend in obesity since 2009.
The first drugs that people consume are tobacco, alcohol and cannabis, and this consumption begins at an early age of between 16 and 18 according to the Survey on Alcohol and Drug Use in Spain (EDADES – 2017 data) or even earlier at the age of 14 according to the Survey on Drug Use in Secondary Education in Spain (ESTUDES).
Whereas heavy smoking on a daily basis has fallen by half in the last ten years, lower levels of consumption, especially the consumption of fewer than ten cigarettes, has risen by more than 40%. Daily consumption of alcohol has fallen in recent years, reaching a historic low in 2017 of 7.4%. Similarly, high alcohol consumption dropped in 2017. Nevertheless, binge drinking has risen considerably from 4.9% of the population aged between 15 and 64 in 2005 to a record high of 17.9% (18.6%, age-adjusted) ten years later.
With regard to the consumption of other drugs, the illegal drug most consumed by people aged 16 to 64 is cannabis. Between 2011 and 2015, the population aged 15 to 64 that smoked cannabis on a daily basis rose by half a percentage point. There are twice and up to three times the percentage of cannabis consumers, and particularly problem cannabis users (those who obtain a score higher than four on the Cannabis Abuse Screening Test), as there are of users of other drugs such as cocaine, ecstasy, amphetamines, hallucinogens, heroin and volatile inhalants.
The profile of cannabis consumers is characterised by a much higher percentage of pupils who have to repeat a year of schooling, have poor marks at school (failed subjects) and poor relationships with their parents and who consume a number of different drugs (polyconsumption), problems that are exacerbated among troublemaking cannabis consumers. The data in the Survey on Alcohol and Other Drugs in Spain (EDADES) also show that cannabis use is associated with a higher prevalence of problems with family, friends and their physical health, psychological issues, traffic accidents, problems at work, financial difficulties, problems with the police or the law, having sexual relations that in other circumstances would not have occurred or having unprotected sex.
OBESITY AMONG CHILDREN AND TEENAGERS
Obesity is a serious public health problem. It is associated with an increased risk of suffering from coronary and cardiovascular diseases, diabetes and certain types of tumours, and it is also linked with a higher probability of mental health problems (Eurostat, 2018). All of this implies substantial direct and indirect costs that put tremendous pressure on the health system as a whole. It is particularly worrying in the case of children, among whom there is a very high prevalence of obesity that has risen continually over the last ten years. Obese children tend to remain obese in adulthood and have a greater likelihood of suffering at an earlier age the diseases associated with obesity. In 2017, obesity affected 20% of children between the ages of two and four, 16% of those aged between five and nine, and 4.7% of those aged between ten and 14.
Obesity rates drop during adolescence but rise once again as teenagers grow older: in 2017, obesity affected 3.2% of teens aged between 15 and 17; 8.2% of young adults aged between 18 and 24 (compared with 5.5% in 2006); and 11% of adults aged between 25 and 34.
BINGE DRINKING AND OTHER PROBLEMS
Binge drinking is a phenomenon associated particularly with young people. In 2017, 25% of young people aged 20 to 24 had engaged in binge drinking in the last 30 days. It is more common among men than women. Moreover, young people’s consumption is associated with high-proof alcohol.
If we compare the data for Spain with the figures for European Union countries, the European Health Interview Survey data show that binge drinking in the last twelve months is also concentrated in other countries among younger age groups, particularly among young adults aged between 20 and 24. In any event, Spain is one of the countries with the lowest percentage of binge drinkers. If we analyse these data in conjunction with the population’s socio-economic circumstances, we can see that in general, apart from the occasional exception, in most European Union countries, including Spain, binge drinking increases as income rises (the higher the income quintile, the higher the percentage of the population that engages in binge drinking).
Binge drinking is particularly serious due to its association with the consumption of other drugs. According to the Survey on Alcohol and Other Drugs in Spain (EDADES and the Survey on Drug Use in Secondary Education in Spain (ESTUDES), drug use is more common among students who have engaged in binge drinking than among those who have not. The data in the 2015 Survey on Alcohol and Other Drugs in Spain (EDADES) show that one in five people who engaged in binge drinking consumed cannabis, whereas among those who did not, the prevalence was below 5%.
The data in the 2017 Survey on Alcohol and Other Drugs in Spain (EDADES) also point to the fact that certain problems are more widespread among those who binge drink than among the general population aged 15 to 34. Whereas 3.4% of the population aged 15 to 34 have had problems or fights with family or friends, this percentage rises to 8.9% among those who have engaged in binge drinking in the previous 30 days. This disparity can also be seen in problems to do with physical health (3.3% as opposed to 1.6%), road accidents (1.7% as opposed to 0.7%) and having unprotected sex (4.2% as opposed to 1.4%).
3. Third challenge:
To guarantee access to healthcare
In Spain, virtually every citizen has healthcare coverage. According to the data in the 2017 National Health Survey, 99% of citizens receive public healthcare through the National Health System or through a government-funded mutual society that contracts healthcare out to private provider. In addition, almost no-one states they have been unable to go to the doctor due to the high cost or because it was too far to travel or they would have had to wait too long.
This nigh-on universal coverage does not, however, guarantee effective access to the package of services required to safeguard people’s health. Firstly, there are areas of care that the public health system does not cover completely in Spain, such as dental and psychological care, some vaccines and certain rehabilitation treatments. In other instances, such as prescription charges, patients contribute to the financing of health spending by making a copayment. In such cases, a lack of financial resources may to a certain extent make access to healthcare difficult. Moreover, there are social minorities excluded from the right to healthcare whose situation is difficult to ascertain through household surveys. Notable among such groups are undocumented immigrants, who were excluded from regular healthcare coverage by Royal Decree Law 16/2012 except in special circumstances (children, pregnant women, emergencies, asylum seekers and human-trafficking victims). This situation was subsequently reversed by means of Decree Law 7/2018.
Barriers to healthcare do not derive solely from low incomes that make it difficult for some families to cover the costs of copayments or of services not provided by the public health system. If the health system does not operate as it should, citizens may not receive the attention they require to safeguard their health in a timely manner. Limited human and material resources lead to excessively long waiting lists and reduce the time doctors can devote to patients, thereby increasing the risk of errors in diagnoses or treatment regimes. Similarly, organisational and management failings can mean that available resources are not used in an optimal manner. For families on medium and low incomes, who do not usually have complementary private health insurance, it is especially important for the health system to work well. The data in the last National Health Survey, conducted in 2017, reveal that 15% of the adult population has private health insurance, but there are significant differences depending on income level: among families with a net income of less than €1,050 a month, fewer than 4% have private health insurance, as opposed to 41% of families with incomes of more than €3,600 a month. One of the problems that traditionally worry health system users in Spain is waiting lists. According to the data in the last two health surveys, between 15% and 20% of adults who needed medical attention in the previous year indicated that they had not received this care or had been given it too late on at least one occasion due to the existence of waiting lists. Even though this question did not feature as such in earlier surveys, making it difficult to analyse changes, the perception of the problem seems to have been no better in 2017 than it was in 2014. The official figures for waiting lists for surgery show that since the start of the economic crisis, there has been an increase in the number of patients waiting for an operation. Moreover, the average waiting time has grown (from 70 days in 2006 to a maximum of 115 in 2016). More recent data show there has been an improvement but the figures remain worse than they were prior to the economic crisis.
Dental care is one of the areas with a very limited public service, although there has been a gradual expansion to cover children in recent times. This means that visiting the dentist is an expense that families find difficult to meet in times of financial hardship. The inability to access dental care fell in Spain in the years leading up to the financial crisis but worsened during the recession, with 7% or more of adults unable to visit the dentist in the period 2012-2014. The reasons families gave for this were overwhelmingly financial rather than any difficulties related to transport, the distance to services or waiting lists.
SOCIAL INEQUALITIES AFFECTING ACCESS
Difficulties in accessing healthcare vary according to income level, but income is not always the determining factor. In the case of a lack of medical attention or excessive delay due to waiting lists, only those with very high incomes of more than €3,600 a month in 2017 presented indicators that were clearly lower than the average (figure 10).
In addition, these people were the only group for whom the situation did not worsen between 2014 and 2017.
The public authorities and citizens share the cost of medication needed to treat health problems. The copayment mechanism is useful for reducing public spending and, in theory, it makes the use of medication efficient. However, inadequate design may have a detrimental impact on health and equity of access. This may occur if people, for financial reasons, reduce compliance with the treatment necessary to safeguard their health or have to spend an excessive proportion of household income on medication.
The Health Barometer indicates that among those surveyed, the percentage of people who for financial reasons have stopped taking medication prescribed by the public health system has fallen. However, this percentage has doubled to over 10% among groups such as the unemployed. Even though this copayment on medication has varied since 2012 in accordance with the patient’s income level, there are no monthly upper limits to what patients pay except in the case of pensioners. Among the unemployed, only those whose benefit entitlement has run out are exempt from this copayment and the rest have to pay just like people in work.
Spending on medical treatment and other health items and services that are not fully covered by the public system can be difficult for people on low incomes who have health problems. According to European criteria, healthcare spending is regarded as catastrophic when it absorbs more than 40% of the household’s ability to pay once spending to cover basic standard consumption in food and housing, energy and water has been taken into account. The incidence of catastrophic health spending among households in the first quintile almost doubled between 2006 and 2014 due to the combined impact of the financial crisis and the reform of the medication copayment system, and it did not begin to drop until 2017.
WHEN TAKING CARE OF HEALTH COSTS TOO MUCH
The two most recent Living Conditions Surveys make it possible to analyse the difficulties people face in accessing basic public services. The data collected show that in 2016, nine out of every ten households had used health services in the previous twelve months (GP, specialist, dentist, prescriptions, etc.). Six out of every ten families had to make health-related payments at some point, and for one in ten covering this spending was difficult or very difficult. The degree of difficulty is clearly connected with income level: it affected 20% of people in the first income quintile, but just 4% of the group with the highest incomes.
The 2017 survey contained different questions, but it too confirmed that health-related payments are a major burden for some families. Particularly notable is spending on dental care, which is perceived as a heavy financial burden by 26% of the population (a quarter of users). In the case of spending on other specialists or purchasing medication, the percentage exceeds 10% in the quintile with the lowest incomes, and is 5% or less among the highest-income group.
THE HEALTH SERVICE IN TIMES OF CRISIS
Official data regarding waiting lists published by the Ministry of Health since 2003 show that there is an objective reality behind citizens’ perceptions. The number of patients on a structural waiting list for surgery (meaning patients waiting for an operation and whose wait is attributable to the organisation of available resources) and the average number of days spent waiting fell in the years prior to the economic crisis but rose rapidly in 2011 and 2012, two years in which the public’s perception of the problem worsened.
4. Fourth challenge:
To guarantee access to dependency care
Dependency care is a right whose full provision as the fourth pillar of the welfare state (together with education, pensions and healthcare) is essential for meeting the needs of an ageing society. In Spain, the system for providing care to dependent people was launched just over ten years ago following the approval in December 2006 of Law 39/2006 on promoting personal independence and care for dependent people. The implementation of this system has been gradual and very slow, coinciding, as it did, with the economic crisis. Consequently, the indicators concerning the coverage and adequacy of the care provided are particularly important in this realm in order to evaluate unmet needs and to plan the additional investment needed.
One of the problems of the System for Autonomy and Dependency Care (SAAD), introduced in 2007, is the long wait before care benefits are received. In 2012, five years after the system came into operation, almost a quarter of the people assessed as dependent were waiting to receive care. During the financial crisis, the registered waiting list fell gradually, but this was due in large measure to the fact that the process for new dependency recognitions was halted and the deadline for incorporating moderately dependent people was extended to 2015. At the end of 2017, the percentage of dependent people waiting to be attended to was still similar to that recorded in 2012, though there was a downward trend.
Senior citizens are the main users of the dependency care system, as more than 70% of all beneficiaries are over the age of 65. For this group, it is possible, moreover, to estimate the real demand for care using the replies given in health surveys concerning their difficulties in performing basic activities of daily living (feeding themselves, getting out of bed, dealing with personal hygiene, etc.) and instrumental activities of daily living (cooking, shopping, household chores, etc.). If we apply an approximation of the official scale, we find that around 15% of senior citizens face limitations severe enough to require care provision by the SAAD. Among people aged over 80, the dependency rate is much higher, verging on 33%. The percentage of dependent senior citizens showed a slight downward trend in the period 2009- 2017. The improvement is particularly noticeable among people aged between 65 and 79, as they enjoy greater autonomy than ten years ago. The evolution of this social need in the future will depend on the outcome of two opposing forces: the ageing of the population, which will lead to increased demand for care, and the overall improvement in people’s health, which could result in a reduction in the demand for care.
The implementation of the dependency care system has had a positive impact on access to long-term care, especially among the elderly over 80 years of age. However, the need for care remains insufficiently met if we bear in mind the figures on senior citizens’ limitations found in health surveys. In 2017, almost half the senior citizens with an estimated need for care were outside the system. In many cases, these are people who have not applied to be assessed (or re-evaluated) by the SAAD as dependent. In some instances, people have requested this but their assessment has not yet been finalised.
This unmet need for dependency care is also reflected in the responses given by senior citizens who find it difficult to perform activities of daily living on their own: more than four in ten state they do not receive any help or that they receive less help than they require. The self-perceived need for help has fallen in the 65 79 age group, but not among those aged 80 and over, half of whom feel they need more help with at least one basic or instrumental activity of daily living. To meet this social need to a satisfactory degree, the care provided needs to be increased in both breadth and depth.
In addition to reaching all those who need care, the system ought to provide services that are sufficient and appropriate to needs. A major problem for the SAAD from the outset has been the excessive importance of financial benefits over direct services, and in particular the emphasis on the financial benefit paid for care in the family environment. This benefit, intended in the law to be exceptional, is a very small amount of financial aid granted to the family member caring for a dependent person in a manner that is incompatible with services such as home care or day centres. These benefits began by exceeding 50% of the total and still in 2014 were more than 40%, though there are major differences between autonomous communities. By late 2017, these benefits accounted for a third of the total, still a long way from the limited role they were intended to play by the law. This indicator reveals the degree of professionalisation in the SAAD: the lower the total financial aid for care in the family environment, the greater the professionalisation.
THE CONSTRUCTION OF THE SYSTEM FOR AUTONOMY AND DEPENDENCY CARE (SAAD)
The number of dependent people served by the SAAD increased rapidly in the early years after the law came into force and amounted to more than 700,000 users in 2011. At that point, the number stabilised due to regulatory and procedural changes that slowed the incorporation of new cases and delayed the inclusion in the system of people with moderate dependency (those with the lowest level of dependency on the scale of those with a right to care). In 2015, the number of beneficiaries began to rise again, eventually exceeding more than a million people in 2017.
The evolution in the registered waiting list reflects the various periods of advances and halts as the system moved towards full implementation. The reduction in the waiting list in recent years is different in nature to the fall that occurred in the period 2012-2015, which was due more to the deaths of people waiting for benefits than an increase in the number of beneficiaries.
CARING FOR DEPENDENT RELATIVES: A HARD TASK FOR FAMILIES
According to the 2016 Living Conditions Survey, some 3 million (amounting to one in six) households have someone at home who needs care due to their advancing years or because they suffer from a chronic illness. Of these, only 14% receive care at home from a paid carer, and only 4% of them have more than 20 hours of care a week. In general, families must pay for this care, especially when the number of hours rises, be it for services contracted privately or because of the copayment demanded by the SAAD (the data makes it impossible to distinguish between these two situations). It should be remembered that the maximum home care provided by the SAAD is around 16 hours per week in the case of extremely dependent people. Almost half of the households who receive these services find the cost of carers difficult or very difficult to cover, and although income levels do make a difference, the gap between income quintiles is not so pronounced as in the case of other types of payment.
As a consequence, there are around 930,000 households with an unmet need for home care, either because they receive no care at all or because the care provision is less than the hours required.
Seven out of ten cases give financial reasons as the grounds for why they do not have the necessary care. However, the second most important reason is the non-availability of these services (10% point to this as the prime reason).
Family involvement in care provision continues to cover some of the gaps in the system: 11% of adults care for a senior citizen or for someone with a chronic illness living in their own home or elsewhere, and 6% spend more than 20 hours a week providing this care. This intensive care, which cannot easily be combined with employment, is provided by women more than by men, and mainly middle-aged women (aged 45-64).