Public trust in the Spanish health‐care system

Abstract

Background  Fifteen years ago, public opinion surveys in Spain showed substantial dissatisfaction with the health‐care system. Since that time, health‐care in Spain has undergone significant changes, including a decentralization of the system, an increase in spending and a change in the way the system is financed.

Objective  This study examines how Spanish citizens rate the performance of their health system today, both as compared with other sectors of society and as compared with earlier time periods.

Methods  Data are drawn from nationally representative telephone surveys of the non‐institutionalized adult Spanish population (age 18 years and over). The study was carried out in two phases: October–November 2005 (n = 3010) and January 2006 (n = 2101).

Results  The majority of the Spanish population thinks the health system needs to be changed. The problems cited relate mostly to long wait times to get health‐care. Nevertheless, over the last 15 years, the proportion of people who have very negative views about the health system has decreased by half. The majority believes that not enough money is spent on health‐care, but few people would support an increase in taxes to provide additional funding. The survey finds the National Health System’s institutions and health professionals to be more highly trusted than other institutions and professional groups in the country.

Conclusions  Government policy‐makers in Spain face a dilemma: the public wants more health spending to decrease wait times, but there is substantial resistance to increasing taxes as a means to finance improvements in the system’s capacity.

Introduction

This paper aims to examine public attitudes towards the Spanish Health System in 2005–2006. Spain is a country of 42 million people. Health‐care in Spain has undergone significant changes over the last 15 years. Spain has a National Health System organized through 17 Regional Health Services plus the African territories of Melilla and Ceuta. The country currently uses 8.1% of its GDP on health spending, a figure slightly lower than the Organisation for Economic Co‐operation and Development (OECD) average for 2004. Table 1 indicates some additional Spanish statistics. ¹ , ² The current National Health System is the long‐term result of a system of health‐care provision initiated in 1942 following the Spanish Civil War. General Francisco Franco’s regime ‘instituted a national mandatory sickness programme financed through social security contributions, and directed primarily to cover the industrial workers and their dependants’. Gradually, enrolment in the programme was extended to other working sectors of the population, and by the 1980s, 83% of the population benefited from the social security‐based health system. ³

Table 1.

 Spanish health‐care statistics (2004)

Statistic	Numbers
Health spending per capita US$ (US dollars calculated using PPPs*)	2094
Percentage of GDP spent on health‐care	8.1
Public expenditure as per cent of total expenditure on health	70.9
Life expectancy	80.5
Infant mortality per 1000 live births	3.5
Doctors per 1000 people	3.4
Acute care beds per 1000 (2003)	2.8
MRI (magnetic resonance imaging) units per million population	7.7

OECD, Health Data 2006. ²

*PPP (purchasing price parity) which equalizes the purchasing price of different currencies for a given product or service.

The present health‐care model was subsequently laid out in the late 1980s. Budget allocation and planning were decentralized from the central government to 17 regional authorities, known as Autonomous Communities (ACs). ⁴ Under the previous model, the social security system received 75% of its funding from the working population – as the system was intended for the workers’ benefit, the employer paid 80% and the employee 20%– and the remaining 25% from the government’s tax revenues. As of 1990, the proportions were reversed such that general tax‐based revenue accounted for 72% of expenses. This percentage has grown over time, such that by 1999, public health‐care was funded entirely through general tax revenues. ³ Furthermore, during the same time period, public health coverage was also extended to include those who previously could not afford the insurance. The old system was targeted towards workers, who had both an income and an employer to pay for most of the insurance costs. The current system provides health coverage to all who require it, including illegal residents.

This study examines three key issues about health‐care in Spain today: (i) how Spanish citizens rate the performance of their health system today, both as compared with other sectors of society and as compared with earlier time periods; (ii) the experience of individuals and families obtaining health‐care when they needed it; and (iii) public trust and confidence in the health‐care system in Spain.

Data and methods

Study design

The data presented in this article are drawn from a study of the attitudes and beliefs of the non‐institutionalized adult Spanish population (age 18 years and over). The study was carried out in two phases using separate surveys with nationally representative samples. In the first phase, 3010 individuals were interviewed between 27 October and 21 November 2005. The sample was stratified by AC. In the second phase 2101; Spanish adults were interviewed on 4–8 January 2006. This sample was independent of the first, not a panel where respondents were re‐interviewed, and was not stratified by AC. ⁵

For each sample, adults were randomly selected from the telephone numbers registered in the General Telephone Base (BGT). The BGT includes only landlines and is updated frequently. Landline telephone penetration in Spain is about 97%. ⁶ Within each household, the particular respondent to be interviewed was determined in a statistically unbiased fashion using the Hagen–Collier method. ⁷ This method seeks to eliminate statistical bias by alternating between men and women and older and younger respondents.

The response rates for the two phases of this specific study were not recorded by the survey organization, but the typical response rate for surveys of this type is about 25%. In order to reduce non‐response bias, the results of the two surveys used here were statistically re‐weighted to reflect the actual composition of the adult population of Spain, calculated on the basis of data from the Spanish census. Numerous experimental studies in the United States have shown that results from lower response‐rate surveys, when statistically re‐weighted, are similar in most instances to those from higher response‐rate surveys. ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹²

For results based on the total sample, one can say with 95% confidence that the error because of sampling could be ±1.8 percentage points for each question in the first phase, ±2.2 in the second phase.

The questionnaire was designed jointly by the Harvard School of Public Health and the Fundació Biblioteca Josep Laporte. The survey instrument was 20 min in length and the interviews were conducted by TNS Demoscopia, a survey firm located in Madrid, Spain. The study was funded by Sanofi‐Aventis Spain and by the Catalan Department of Health of the Catalan Government. Throughout our analysis, chi‐squares were calculated for comparisons and statistical significance was set at P < 0.05.

Survey questionnaire

Respondents were asked their assessment of the Spanish health‐care system and what degree of change was needed, how well they thought various institutions in Spanish society were doing their job, what they thought were the most important problems in the Spanish health‐care system, what they thought was the most important thing the government could do to improve health‐care, whether they believed the amount of money being spent on health‐care was too much, not enough, or more or less the right amount, and, if they thought not enough was being spent, whether the additional money should come from an increase in taxes or by the government getting the money from other areas of the budget.

Respondents were also asked how satisfied they were with the medical and health services they and their families used during the past year, their assessment of the supply of doctors in their local area, whether they thought they and their family would have access to the most modern health technology, whether they thought they would have access to a medical specialist without a very long wait and how worried they were about having to wait very long for a doctor’s appointment in a non‐emergency, not being able to afford the medical care they need, and that their parents, grandparents or spouse would not be able to gain admission to a nursing home. Respondents were also asked how much they trusted various groups, including primary care or family doctors and hospital doctors, to do what’s best for society.

Findings

Spanish citizens rate their health system

Twenty‐eight per cent of Spaniards thought that the health system worked well and needed only minor changes. While many Spaniards still felt that fundamental changes to the system were needed, as indicated in Table 2, significantly fewer people now felt that the system needed to be completely rebuilt, as compared with 1991. ¹³ The survey found that people over the age of 65 years (39%) were significantly more likely than people aged 18–34 years (19%) to think the health‐care system works pretty well. Results indicated only a relatively small difference between upper/upper middle class (32%) and lower/lower middle class respondents (27%) in the proportion seeing the health‐care system as working pretty well. ⁵ The overall rating of the Spanish health‐care system was similar to that given by citizens of Great Britain to their own health‐care system in 2004, where 26% felt only minor changes were needed, 59% said fundamental changes were needed, and 13% said the system needed to be completely rebuilt. ¹⁴

Table 2.

 Views on health system in Spain, 1991–2006

Per cent who say the system	Per cent
2006*
Needs minor changes	28‡
Needs fundamental changes	58‡
Must be completely rebuilt	13
1991†
Needs minor changes	21
Needs fundamental changes	49
Must be completely rebuilt	28§

*Harvard School of Public Health and Fundació Biblioteca Josep Laporte, Trust in the Spanish Healthcare System, 2005/2006. ⁵

†Blendon et al.‘Spain’s citizens assess their health care system’. ¹³

^‡Statistically larger proportion than in 1991 at P < 0.05.

^§Statistically larger proportion than in 2006 at P < 0.05.

The survey also asked respondents to evaluate various institutions encompassing different facets of Spanish society (Table 3). The public rated the three health‐care‐oriented institutions that were asked about – publicly funded primary health‐care centres, public hospitals and pharmaceutical companies – higher than other non‐health institutions. This is a strong indication that Spaniards today believe that health‐care institutions are doing their jobs well and rate them higher in terms of performance than other sectors of Spanish society. Notably, the government was rated the lowest of all the institutions that were mentioned. ⁵

Table 3.

 Do you think that each of these institutions does their job well?

Institution	Percent saying yes
Health centres or primary public care centres	78
Public hospitals	75
Pharmaceutical companies	69
Universities	63
Spanish railway system	62
Media	56
Banks	52
Airline companies	46
Telephone companies	44
Government	41

Harvard School of Public Health and Fundació Biblioteca Josep Laporte, Trust in the Spanish Healthcare System, 2005/2006. ⁵

Respondents were asked to name in their own words the two most important problems in the Spanish health‐care system; the responses were overwhelmingly centred on wait times of different kinds (Table 4). The top four responses given referred to wait times, be they for specialists, primary health‐care appointments, or surgery. Not surprisingly, therefore, when respondents were asked about the most important action the government could take to improve health‐care, the most common response throughout Spain was to hire more physicians (Table 5). The lack of prompt medical attention appears to be the most significant issue affecting the Spanish public’s satisfaction with its health system. Other issues such as poor quality of patient care rated much lower as concerns. ⁵

Table 4.

 What are the two most important problems in the Spanish health‐care system?

Problem	Per cent
Wait times	29
Wait times for specialists	17
Wait times for operations	14
Wait times for family care doctors	11
Lack of patient care	8
Overcrowding	7
Poor patient care	6
Lack of resources	5
Wait time in emergencies	4
Lack of doctors	4
Lack of health‐care personnel	4
Small amount of time spent by doctors with patients	3
Wait times for exams	3
Financing	3
Organization	2
Slowness	1

Harvard School of Public Health and Fundació Biblioteca Josep Laporte, Trust in the Spanish Healthcare System, 2005/2006. ⁵

Table 5.

 What is the most important action the government could take to improve health‐care in Spain?

Action	Per cent
Hire more doctors	25
More personnel	13
More hospitals/centres	13
Invest more money	12
Remove wait lists	8
More resources/means	5
More nurses	3
Better efficiency	3
Better treatment/care	3
Increase outpatient department hours	2
Improve medical training	2
Control the doctors more	2
Faster medical care	1
More facilities/operating rooms/beds	1
All types of patient assistance	1

Harvard School of Public Health and Fundació Biblioteca Josep Laporte, Trust in the Spanish Healthcare System, 2005/2006. ⁵

In a publicly supported health system like the one in Spain, the availability of health‐care resources is primarily dependent on the amount of money that can be spent on the health‐care system by the government. This money is allocated by regional governments and their respective parliaments. When asked about government spending on health‐care, respondents indicated a need for more funding, although they were generally unwilling to provide the additional money themselves. Despite increased spending on the Spanish health system in the last several years, over half of all respondents (56%) said that not enough money is spent on health‐care in Spain. However, barely one in seven of respondents (14%) indicated that they would support an increase in taxes to provide the necessary additional funding. ⁵

The experience of individuals and families obtaining health‐care

Overall, Spanish citizens were generally satisfied with the health services that they and their families received in the last year (Table 6). The survey found that the level of public dissatisfaction with health services has seen a small but statistically significant decrease since 1991. People over the age of 65 years were more likely than people in other age groups to say that they were ‘very satisfied’ with the services received (50%), while people between the ages of 18 and 34 years were generally less likely to give the same response (22%). Of note, similar levels of satisfaction and dissatisfaction were found between all income levels, and different regions of the country also demonstrated comparable degrees of satisfaction, suggesting a considerable degree of equity throughout the country. Compared with the 1991 survey, Spaniards expressed higher expectations on their health‐care system. ⁵ , ¹³

Table 6.

 Spanish citizens’ satisfaction with the medical and health services they have used in the last year

Level of satisfaction	Per cent
2005*
Total satisfied	79‡
Very satisfied	32
Somewhat satisfied	47
Total dissatisfied	19
Somewhat dissatisfied	13
Very dissatisfied	6
1991†
Total satisfied	71
Very satisfied	28
Somewhat satisfied	43
Total dissatisfied	28§
Somewhat dissatisfied	18
Very dissatisfied	10

*Harvard School of Public Health and Fundació Biblioteca Josep Laporte, Trust in the Spanish Healthcare System, 2005/2006. ⁵

†Blendon et al.‘Spain’s citizens assess their health care system’. ¹³

‡Statistically larger proportion than in 1991 at P < 0.05.

§Statistically larger proportion than in 2005 at P < 0.05.

When asked about the adequacy of the number of physicians in their area, more than half of respondents (53%) believed that there was a shortage of physicians. Interestingly, nearly the same proportion of people in large cities as small communities thought that there were not enough doctors in their area, despite the higher concentration of doctors in urban centres. ⁵

In addition, despite significant increases in spending and availability of modern health technology, one‐third of respondents (33%) still believed that they did not have access to this technology. The survey found that people aged 18–24 years were less likely than people over the age of 65 years to say they had access to the most modern health technology (49% compared with 59%). ⁵

Corresponding to the overall concerns regarding wait times, only 29% of Spaniards believed that they would have access to a specialist without being on a wait list for very long if they needed to see one. Over half of Spaniards (53%) were ‘very worried’ that they would have to wait long to see a doctor in a non‐emergency situation. Furthermore, people of lower income were more likely to be ‘very worried’ about this than people of higher income (59% vs. 49%), while senior citizens were much more likely to say that they were ‘very worried’ than people aged 18–24 years (58% vs. 42%). ⁵

Although the Spanish health system covers the majority of the public’s health‐care costs, there was still widespread concern that people would not be able to afford the care that they might need in the future. Seven in 10 respondents were ‘very worried’ about this problem (70%). Respondents also voiced concern that their parents, grandparents or husband/wife would not be able to gain admittance to a nursing home if they needed to. Seven out of 10 respondents (71%) were ‘very worried’ about this issue. Additionally, respondents expressed concern about the restrictions placed on their health‐care, as more than half of them (56%) thought that primary care doctors face limitations from the government or health managers as far as offering patients all the assistance they need. ⁵

Public trust in health‐care in Spain

Public trust in different institutions is an important indicator for a number of reasons. Most importantly, people may be more willing to heed advice from trusted groups or institutions on important issues. Furthermore, people tend to be respectful of these groups’ views on national as well as regional issues. In terms of public trust, health‐care institutions ranked very highly in the minds of Spanish citizens. When respondents were asked how much they trusted that professionals from different institutions try to do what is best for society, hospital doctors and primary care doctors ranked as two of the top three most trusted professions (Table 7). ⁵

Table 7.

 How much do you trust that these professions try to do what’s best for society?

Profession	Per cent saying very much
Scientists	66
Hospital doctors	64
Primary care or family doctors	62
Elementary and high school teachers	49
University professors	45
Journalists	23
Lawyers	20
Economists	20
Politicians	11

Harvard School of Public Health and Fundació Biblioteca Josep Laporte, Trust in the Spanish Healthcare System, 2005/2006. ⁵

Attitudes in different regions of Spain

Spain encompasses many regions, all with differences in culture and health resources. As a result of these variations, we expected to find substantial differences between regions on a number of measures. However, on key indicators, there were no significant differences between regions, as shown in Table 8. ⁵

Table 8.

 Attitudes in different regions of Spain

Issue	Total (%)	Andalucia	Calatuña	Madrid	Rest of Spain
Health‐care system*
Needs only minor changes	28	28	25	24	29
Needs fundamental changes	58	56	61	61	57
Must be completely rebuilt	13	14	10	14	12
Satisfaction with services in past year*
Very satisfied	32	30	31	31	34
Somewhat satisfied	47	49	47	47	46
Somewhat dissatisfied	13	13	12	16	13
Very dissatisfied	6	7	8	6	5
Number of doctors in place of residence*
Too many	2	1	3	2	3
Too few	53	55	54	59	50
Right amount	41	41	40	35	43
Access to modern health technology
Yes	57	53	61	56	57
No	33	34	29	33	33
Don’t know	11	12	10	12	10
Access to specialist without long wait time*
Yes	29	30	30	26	30
No	64	65	63	67	64
Long wait time for doctor in non‐emergency*
Very worried	53	54	52	57	52
Somewhat worried	33	31	32	34	33
Not at all worried	14	15	15	9	14

Harvard School of Public Health and Fundació Biblioteca Josep Laporte, Trust in the Spanish Healthcare System, 2005/2006. ⁵

*‘Don’t know, responses not shown when under 10%.

Conclusions

A majority of the Spanish population thinks the health system needs to be changed and improved. However, over the last 15 years, there has been a substantial improvement in the public’s views about how well the Spanish health system operates. Most significantly, during this time period, the proportion of people who have very negative feelings towards the health system has decreased by half. There has also been an increase in the proportion of people who see the system as working well, but this figure is not as significant as the former.

During the same period, there was a small but statistically significant improvement in citizens’ reports about their individual experiences with health‐care in the last year. These data suggest an apparent sense of equity across the country. The results do not differ substantially between social status, geographical region or population size. The only notable difference is that young people appear to be more critical of the health system than other age groups.

Another important finding is how much health‐care institutions and professionals are trusted among the general public. On almost every measure, they rank higher than other institutions and professional groups in Spain. Also of interest, the public demonstrates a high level of trust in the publicly funded provision of health services at a time when there is a low level of trust in government in general.

Although people are more satisfied with the health system, they see a serious problem with wait times to get care. In addition, a substantial minority of the population does not think that the latest medical technology is available to them or that there are enough physicians in their area. Spaniards also express fears about the possibility of not being able to afford health‐care in the future, as well as concerns about long wait times to receive it. This may reflect public concern about a future shortage in economic resources. Government policy‐makers in Spain face a dilemma: although the public wants more health spending to decrease wait times, there is substantial resistance to increasing taxes as a means to finance improvements in the system’s capacity.