Una evaluación de la calidad y la equidad del Sistema Nacional de Salud desde la perspectiva de los pacientes

Doctoral thesis defended on June 20, 2023 by Juan David García-Corchero in the Department of Applied Economics of the University of Granada directed by Professor Dolores Jiménez-Rubio (University of Granada). She obtained the grade Outstanding-Cum laude. Court: Marta Ortega-Ortega (Complutense University of Madrid); Ángeles Sánchez-Domínguez (University of Granada) and Manuel Serrano Alarcón (Joint Research Center-European Commission).

summary

Evaluating the health system is key to analyzing the effectiveness of public policies and identifying possible access barriers and/or deficiencies in health services. This doctoral thesis evaluates the determinants of healthcare quality from the perspective of patients, while examining the possible sources of socioeconomic inequalities in a universal and decentralized healthcare system such as the Spanish National Health System (SNS). Along with other conventional measures of health service performance, quality indicators based on the perspective of patients can improve the monitoring of health services, as well as assist in decision making.

Chapter 1. How do health policy instruments influence the quality of services?

The first chapter (and article) explores the determinants of satisfaction with the Spanish health system – a measure increasingly used to measure the perceived quality of health systems – through the use of multilevel statistical techniques and using the Health Barometer as the primary source of data. This database offers relevant information on opinions, attitudes, use and perceptions about the functioning of health services in Spain.

As graph 1 shows, there is a high level of geographical disparity in citizens’ perceptions regarding healthcare.

Figure 1. Average satisfaction with public health in each autonomous community, 2002-2016

Fountain: Health Barometer (2002-2016). Ministry of Health.

Taking advantage of this geographical variability, this first chapter seeks to provide empirical evidence of the role that health policy instruments play in improving levels of satisfaction with public health in Spain. Given that many of the factors analyzed (notably public healthcare spending and clinical staffing ratios) are directly subject to the influence of policy makers, our study provides a better understanding of the key determinants of healthcare quality. As we can see in graph 2, at the national level there is a strong level of compensation between the evolution of public spending and the average level of satisfaction with healthcare.

Graph 2. Average satisfaction with public healthcare vs. public spending on healthcare per capita, 2002-2016

Grades: N=6,825. Results of estimating a multiple linear regression by the ordinary least squares method where the dependent variable is waiting times for the specialist. 95% confidence intervals obtained from estimates of waiting times for specialized care. Data from the Health Barometer for the 2011-2013 waves. Our reference region is Andalusia.

The results indicate that improvements in healthcare investments, especially in the area of ​​clinical staff, have the potential to improve satisfaction levels. Our results highlight the importance of disaggregating the analysis by services as it can detect significant associations between variables that may not be evident in a more aggregated analysis.

Furthermore, the growing importance of the private sector in some regions may reveal certain problems in the functioning of the Spanish SNS from the point of view of citizens. This increasing dependence on private insurance highlights characteristics of private healthcare that could be highly valued by patients, such as possible shorter waiting times and greater freedom of choice of healthcare provider. Thus, a worsening of the quality of public healthcare could drive higher-income individuals towards the private sector. Greater use of private healthcare, coupled with taxpayers’ perceived low quality of care received, could lead to less support for improvements in the financing of public healthcare systems.

Chapter 2. Waiting times in healthcare: equal treatment for the same need?

The second chapter (and article) identifies the main determinants of waiting times in healthcare, one of the key domains of healthcare responsiveness and one of the most important determinants of satisfaction with the healthcare system. In particular, in this chapter we explore whether there is a socioeconomic gradient in waiting times during the initial phases of contact with the Spanish health system, both in primary and specialized care. Additionally, this chapter explores the extent to which the socioeconomic gradient is maintained after controlling for other sociodemographic differences, such as nationality, area of ​​residence, or fluency in Spanish.

Our results provide evidence of the existence of a moderate socioeconomic gradient in primary care, based on occupation variables. However, for specialized care we do find a very pronounced socioeconomic gradient. Thus, as can be seen in graph 3, individuals with university education tend to report waiting times between 10.6-18.7% shorter. In particular, patients with university education achieve an advantage in waiting times of between 9-16 days. On the other hand, in line with previous literature, in the case of primary care services we only found evidence of inequalities based mainly on sex (favoring men) in line with the results obtained for specialty care, severity (favoring to individuals in better health) and the area of ​​residence (favoring rural areas).

Graph 3. Predictive factors for waiting times in specialized care (number of days)

Grades: N=6,825. Results of estimating a multiple linear regression by the ordinary least squares method where the dependent variable is waiting times for the specialist. 95% confidence intervals obtained from estimates of waiting times for specialized care. Data from the Health Barometer for the 2011-2013 waves. The reference individual is a male without education, inactive, between 18 and 34 years old, without chronic diseases, without visits to private family doctors, Spanish, fluent in Spanish and living in an urban area.

Thanks to the richness of our data, we can investigate possible selection bias in access to specialized healthcare. In this sense, it is possible that some users of private healthcare systems only resort to the Spanish SNS when waiting times are relatively shorter in public healthcare. This pattern of use could skew the socioeconomic gradient. Our results clearly suggest that patients resort to private healthcare to a greater extent when waiting times to receive specialized care from the Spanish NHS are above the median. Regarding territorial inequalities, if we analyze the coefficients of the fixed effects by region in graph 4, we see important differences, with Madrid and La Rioja standing out as the communities with the shortest waiting times for specialist consultations compared to Andalusia.

In short, there is an important socioeconomic gradient for specialized care (favoring patients with a higher educational level), regardless of the presence of selection bias.

Graph 4. Coefficients of the regional fixed effects of the regression model for waiting times in specialized public care

Fountain: Health Barometer (2002-2016). Key Indicators of the National Health System. Ministry of Health.

Chapter 3. Is there a political demand for private healthcare?

The third chapter focuses on political identity as a determinant of the demand for healthcare. In particular, we focus on the role of political narratives in the use of private healthcare within publicly funded universal healthcare systems. For this study, we take advantage of the geographical variability in the implementation of austerity policies in the public health system as can be seen in graph 5.

Graph 5. Regional heterogeneity in the application of the 2012 austerity measures

Note: “Intensely treated provinces” in red and “Less intensively treated provinces” in pink based on Bacigalupe et al. (2016)

Our results show a significant increase in the number of specialist consultations and private hospital stays among supporters of conservative parties residing in regions that have experienced more intense budget cuts. Specifically, our estimates show an increase of 28.85-34.23% by the “most conservative” citizens in the number of visits to private specialized services in regions where the 2012 budget cuts in the SNS are intensively applied. Spanish. Along the same lines, the number of visits to private hospitals increases by 207-211% after the austerity measures. We also find evidence of stronger effects of political ideology on private healthcare utilization as a function of socioeconomic level (higher income) and (better) health status.

As mechanisms behind these results, we observe an increase in the outsourcing of health services and household spending on private health insurance in regions where budget cuts are applied more intensely. Additionally, public wait times are also increasing in these regions. These results suggest that austerity policies lead to lower quality and congestion in healthcare, which “ideologically” motivates the use of private healthcare services by more conservative citizens.

Conclusion

In summary, the results of this doctoral thesis suggest that any deterioration in the satisfaction and responsiveness of the Spanish NHS should be of particular concern, as the dissatisfaction and lack of voice of taxpayers, combined with a growing importance of private healthcare, could transform universal healthcare systems, in the words of Appropriate (2000), in a «bad service for the poor.» This consideration is of special interest in light of the challenges that many countries, not just Spain, currently face. Among these challenges are the effects that the COVID-19 pandemic has had (and is having) on ​​health systems, growing deficits in the public sector and the progressive aging of the population in a context of political polarization. Studies such as this one can help policymakers and managers monitor the functioning of health systems, offering evidence-based policy recommendations that assess not only the efficiency but also the equity and quality of health services.