Impacts of austerity on healthcare access in Spain, and responses from social movements

By Javier Segura del Pozo, Javier Padilla, Vanessa Puig Barrachina and Davide Malmusi

Budget cuts and privatisation

In Spain, the change in the system of entitlement (from universal to employment-based) and the increase and extension of prescribed drug copayments [0], together with a constellation of regional cost-saving measures, are only some of the changes that are provoking impacts on the access, quality and out-of-pocket expenditure for public healthcare. Most importantly, Spanish national and regional governments, ruled mainly by conservatives parties, have made good use of budget cuts targets to advance the privatisation process of the prestigious public funded and ruled Spanish Health Service.

Picture of the front page: “White wave” manifestation in Puerta del Sol square (Madrid) against the regional health care system privatisation initiatives. Source: RTVE web

The officially argued savings in public-private join initiatives (compared to performances of 100% public health services) have been neutralized by the weak existing evidences about private efficiency [1] [2] [3] and the overwhelming news about conflicts of interest, nepotism, monopolistic dynamics, influence peddling and «revolving doors» between government politicians and private health care enterprises managers [4] [5] [6][see complementary text under the second picture].

Reactions from the civil society

These privatisation initiatives and cuts found a strong and unexpected resistance, not only amongst civil society, very satisfied with their health care services, but amongst health care staff who are firmly defending the public health care system. A historic unity, linking all types of professionals (doctors, nurses, health workers) in different hierarchical positions, converging primary health care with hospital based professionals, has made possible the organisation in Madrid and other regions of a huge movement, called “marea blanca” (white wave), a prolonged strike and a massive mobilisation on the streets with a vast media coverage [7].

A great variety of initiatives among civil society, together with health care professionals, have been born in recent years to reflect on what is possible and how to reverse the privatisation policies of public health system [8]. These initiatives range from advocacy groups, such as La Federación de Asociaciones para la Defensa de la Sanidad Pública (The Federation of Associations for the Defence of Public Health)[9] and in Catalonia Dempeus per la Salut Pública [10] and Centre d’Anàlisis i Programes Sanitaris (Center of analysis and health programs) [11] up to neighbourhood groups who decided to self-manage a Primary Assistance Centre [12] and civil platforms built along the 15-M movement giving notice of appeal to the court against budget cuts alleging that these cuts are killing citizens (Plataforma de Afectadas por los Recortes Sanitarios, Platform of people affected by healthcare cuts) [13] or calling for  civil disobedience against new laws limiting the universal access to health care, specially for immigrants: Yo si, sanidad universal (Yes, I am for universal health care) [14].

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An example of a bad example for Spanish austerity measures legitimacy: The Father, the Daughter and the Son-in-law

• The Father: Carlos Fabra Carreras. Head Partido Popular party (PP) in the province of Castellón (Comunidad de Valencia- Valencia Region) and descendent of three generations (since late XIX century) of powerful conservatives province governors (including during General Franco Dictatorship)  The Valencia region has been pioneering health care privatisations initiatives (Alzira Initiative, Ribera Hospital experience and resulting Salud Ribera company) and also has one of the biggest budget deficits in Spain. The regional PP government announces each year new tax rises and spending cuts. Fabra has been at the centre of corruption allegations, with, among other things, court investigators wanting to know how he regularly appears to win Spain’s El Gordo Christmas lottery – whose  winning tickets are sometimes bought by people trying to launder money. Besides, Carlos Fabra has a 20-tonne copper sculpture in the newly built Castellón airport not yet in use and very questioned over its viability after several airport closures in Spain. The money (€300,000) for the monument in effect comes out of taxpayers’ pockets.
• The Daughter: Andrea Fabra Fernández  She is currently an MP for Partido Popular in the Spanish parliament. Whilst Mariano Rajoy, prime minister of Spain, announced cuts to the unemployment benefits in July 2012, she exclaimed (in agreement) ‘Que se jodan’, literally ‘Fuck them’ (picture in the middle). Her actions caused huge controversy in Spain and a petition was signed by almost 200,000 people calling for her resignation. She provided a rallying cry for anti-austerity protestors in Spain.
• The Son-in-law: Juan José Güemes, former health commissioner for the Madrid region. Recently, announced he was stepping down from his post as a board member of Unilabs (swiss laboratory services multinational company) after a new scandal. Güemes, who served on the Popular Party (PP) regional government between 2007 and 2010, had overseen the privatization of medical analysis services at six Madrid hospitals in 2009, amongst other measures in favour of Madrid’s health care system privatisation process. The contract was awarded to UTE BR Salud, which was purchased by Unilabs last November, five months after Güemes had become a paid advisor at the company.

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Other examples of «revolving doors» in current Spanish health care privatisation process:

1. Manuel Lamela Fernandez, health commissioner for the Madrid region between 2003 and 2007 (when the new private managed-public funded hospitals started), currently president of Madrid Medical Destination S.L. (MCM), company promoting a variety of activities and business in Madrid’s  private health care sector. Among MCM’s clients are Capio, MD Anderson, an international chain of privately run cancer treatment centers, and Clínica La Luz, a private hospital in Madrid. In Spain, two companies dominate the hospital management business: Capio, which is run by risk capital fund CVC Partners, and Ribera Salud, owned in equal parts by two former savings banks based in Valencia: Bancaixa and CAM, now owned respectively by Bankia and Sabadell. 
2. José Ignacio Echániz, the head of Madrid’s health department (before Lamela: 1999-2003) at the time Capio took over the running of the Jiménez Díaz hospital, which has a catchment area of more than 400,000 people, in 2003. He is now the head of health in the Popular Party-controlled region of Castilla-La Mancha, which is set to privatize four hospitals. His sister, Teresa Echániz, now works for Capio at mid-management level.
3. Antonio Burgueño Carbonell, director general for hospitals within Madrid’s Health Department since 2008, is the brains behind the Popular Party-controlled regional government’s plans to privatize the management of six hospitals and 27 health centers next year. He has more than 20 years’ experience working for private healthcare providers such as Adeslas, and was part of the team that set up the Alzira initiative. He has also provided consultancy to Capio, a private healthcare company which built and now runs a hospital in the Madrid dormitory town of Valdemoro that opened in 2007. His son, Antonio Burgueño Jerez, works for Ribera Salud, which in turn advised on the construction of a new hospital, now owned by private medical insurer Sanitas, in Torrejón, just outside Madrid.
4. Manuel Marín Ferrer in 2000 was named Valencia Regional Government commissioner of La Ribera’s health service, and tasked with overseeing the private company that runs the hospital, a post he occupied until 2007. In September of 2007, Marín Ferrer then moved from the public sector to the private, and took over as the new director of the hospital he was once responsible for making sure met its contractual obligations and delivered the healthcare it had agreed to.

Sources: Caption and Box texts have been extracted from:

• The Guardian, 10 January 2012 (http://www.guardian.co.uk/world/2012/jan/10/spanish-politician-accused-megalomania-monument).
• Wikipedia: (http://en.wikipedia.org/wiki/Andrea_Fabra_Fern%C3%A1ndez ).
• El Pais, 18 January 2013 (http://elpais.com/elpais/2013/01/15/inenglish/1358256648_456140.html)
• El Pais, 11 December 2012 http://elpais.com/elpais/2012/12/10/inenglish/1355160134_388674.html

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References

0- Minué-Lorenzo S, García Gutiérrez JF, Mercader-Casas JJ. Beginning of the end  for Spain’s national health system. BMJ. 2012 May 8;344:e3213.

1-  Quercioli C, Messina G, Basu S, et al. The effect of healthcare delivery privatisation on avoidable mortality: longitudinal cross-regional results from Italy: 1993-2003. J of Epidemiol & Comm Health. 2012

2- Peiró S. Meneu R. Eficiencia en la gestión hospitalaria pública: directa vs privada por concesión. Nada es gratis. 27/12/2012. Disponible en: http://www.fedeablogs.net/economia/?p=27263

3- Benach, Joan; Tarafa, Gemma; Muntaner, Carles El copago sanitario y la desigualdad: ciencia y política. Gac Sanit. 2012;26:80-2. – vol.26 núm 01.

4- De la pública a la privada y al revés [From public to private and back] . El País. Dic 2nd 2012

5- Jara, M. (2010). Las puertas giratorias. Disponible, 20 octubre, 2012, en:
http://www.migueljara.com/2010/05/17/las-puertas-giratorias/

6- Güell, O., & Castedo, A. (2012, 10 junio). La acumulación de escándalos agita
la sanidad pública catalana. El País. Disponible, 20 octubre, 2012, en:
http://ccaa.elpais.com/ccaa/2012/06/10/catalunya/1339355699_069772.html

7- Thousands protest austerity, proposed sell-offs of parts of Spain’s national health care. The Washington Post. Dec 9th 2012.

8- Benach J., Muntaner C., Tarafa G., Valverde C. La sanidad está en venta, y también nuestra salud. Barcelona: Icaria, 2012.

9- FADSP (Federación de Asociaciones para la Defensa de la Sanidad Pública) http://www.fadsp.org

10- Dempeus per la Salut Pública http://dempeusperlasalut.wordpress.com/

11- Centre d’Anàlisis i Programes Sanitaris, http://www.caps.cat]

12- Self-managing of a primary health centre in Viladecavalls (Catalonia) and the Cooperativa Integral Catalana (Catalan Integral Cooperative.)

http://www.alasbarricadas.org/noticias/node/18417  and https://cooperativa.ecoxarxes.cat

13- PARS http://afectadasporlosrecortessanitarios.wordpress.com/

14-Yo si, sanidad universal http://yosisanidaduniversal.net/portada.php