An indicator for a more fairly funded primary care

7 Apr
Cristina Colls

The Catalan government has recently expressed its willingness to increase the importance ascribed to the socio-economic level of regions when calculating the budget for each primary care team.

This fact invites us to ask ourselves a question: why is it important to bear in mind the economic inequality in the funding of primary care teams?

The influence of socio-economic inequalities on the health of the population is a fact that has been widely studied since the 60s of last century and of which there is evidence both in the international and national context.

We know that people with a lower socio-economic status have more probability of dying before the age of 65 and that they show more physical and mental health problems during their lives. It is logical, therefore, to conclude that they need to make a more intensive use of health resources.

We also know that social inequality is a recipe for an unbalanced distribution of the population in a territory leading to an accumulation of the most serious social problems in specific municipalities or neighbourhoods that have a greater need for social and healthcare than other regions.

It is in this context that more needs to be done where there is greater necessity if equity in the allocation of resources is to be guaranteed. But where should more resources be provided?

The professionals of primary care teams are those closest to the citizen and therefore, have a comprehensive view of the health needs of the population in their territory.

In addition, the primary environment is the reference in prevention activities, in controlling chronic diseases and from which a large part of community activity is coordinated. For all these reasons, the provision for primary care teams must bear in mind the socio-economic conditions of the population they serve.

How can we find out what the socio-economic situation is of territories in which a primary care primary care team works? Many variables exist which give us indirect information (income, occupation, education, housing conditions, among others) but if we are looking for only one classification we need a unique index that synthesises all these aspects; it is what we call a deprivation index.

Deprivation indexes have been widely used as a tool in social policies because they allow an objective prioritisation to be established in small regions, ranging from a low to high socio-economic status. The concept of “deprivation” refers to unmet needs as a result of a lack of resources, not exclusively economic.

All indexes of deprivation are built by adding up the results of different socio-economic status indicators. The weight given to each indicator could be theoretical, that is, based on what a particular indicator is thought to contribute to the phenomenon of deprivation; or otherwise, the result of a multivariate statistical model.

To be able to classify the basic areas of health (reference territories of a primary care team) according to their socio-economic level, AQuAS has built an index called a composite socio-economic status indicator which synthesises seven indicators: population exempt from drug co-payment, population with incomes lower than 18,000€, population with incomes higher than 100,000€, population with manual jobs, population with insufficient educational attainment, premature deaths or potentially avoidable hospitalisations.

The statistical methodology used for calculating this indicator has been that of principal component analysis. The application of this methodology has allowed us to obtain a socio-economic status map of Catalonia.

The application of the composite socio-economic status indicator has been done within the framework of the redefinition of the model of allocation of resources for primary care and has enabled the identification of those primary care teams which will increase their budgets in coming years.

This new model of allocating resources for primary care is an experience in applying scientific evidence to political action.

Post written by Cristina Colls.

Public health care budget. A ten-year overview (part 1)

24 Sep

Joan-PonsJoan MV Pons, Head of Evaluation AQuAS

In 2007, a high interest health economics research article was published and promoted by the Department of Health1. The study broadcasted the public health care budget for 2005, not only for the 17 categories of the International Classification of Diseases (ICD), but also by the type of assistance and mainline services. There is no doubt that the work provided a reference point for health planning and management and offered an unexpected surprise as, until recently2, the newer data of this kind and obtained using a similar methodology was not being made public. I admit that it has been a personal interest of the Minister to see the data presented in this manner.

And in this interval, 2005-2015, what do the numbers say, more exactly, the euros? First, let’s have a look at the overall graphics and then at its sections.

Sense títol

Let’s start by mentioning that the harsh cuts timeframe was in 2011-2013 when CatSalut’s budget had to be reduced by 1.5 billion Euros compared to 2010, the year when this expenditure (or investment for some and certainly a source of health and financial benefits for many people) reached its peak. Worthy of mentioning is that between 2003-2010, CatSalut’s budget growth far exceeded the GDP growth, but this was a very common trend before the crisis. We will not go along with littleness, by asking whether, despite the reduction in public spending, the budget for social policies (health, education, welfare and family) of the Catalan government has increased in percentage within Catalonian budgets (71.2% in 2015). Accurately, the 2005 health budget represented 40% of the Catalan public budget and in 2015 we have the same percentage, but the amounts are very different. Here we could apply the phrase attributed to both Mark Twain and Benjamin Disraeli regarding the three types of lies: lies, damned lies and statistics.

If we continue down the broad lines of services, we have to study them with graphics such as the following (pressupost = budget):

Sense títol

If we examine the budget distribution among major areas or major lines (functional classification) we notice striking things worthy of mentioning. The first, undoubtedly, is the reduction in pharmacy spending that has reached stratospheric levels in the mid of the last decade, (almost 24% of all health care budget). Plenty of measures with regards to the quality of prescribing have been implemented, from the most effective in price levels and generic to the more educational (professional) and motivating (management by objectives). It’s clear that for many years, the local and foreign pharmaceutical industry, existed in a cloud due to the lack of a genuine public pharmacy policy in this country. For this reason, those covenants that demanded returns of profits with which research networks (ISCIII) were financed and, amusingly, funds for activities aimed at rational drug use that the Ministry distributed among nationalities and regions, emerged.

Therefore the pharmacy spending goes down (as the return of the pharmaceutical industry to research and rational use), but the more particular pharmacy, the high technology pharmacy (biotechnology, whether medicine of recombinant origin or monoclonal antibodies) as is the MHDA (ambulatory drugs dispensed at the hospitals), continues to rise with an absolute increase of 61.6% between 2005 and 2015 (from M€390.29 to M€630.93). A more thorough analysis of the changes in pharmaceuticals expenditure, whether in a hospital or for distribution to outpatients, would force us to examine in more detail the different types of drugs and their use.

We can also notice an increase in spending on health care, both primary and specialized, as the latter grows much more to represent more than half (58%) of public insurance spending. The trend of focusing on hospitals and unrestrained specialized care also comes from afar. We may say, although without the data, that there is an incipient turnaround in recent years, of a slight decrease in specialized care and slight increase in primary care. The growing need for attention to chronic disease and for integration of social services (health and social care), the two sides of the same coin, should go on shifting this situation.

1 Gisbert R, Brosa M, Bohigas L. Distribución del presupuesto sanitario público de Catalunya del año 2005 entre las 17 categorías CIE-9-MC. Gac Sanit 2007;21:124-31.

2 Pressupost del Departament de Salut per a l’any 2015