03 The Welfare State


Putting affairs in order to give value to Public Healthcare

Jaume Puig-Junoy

Despite the still relatively robust condition of public health care in Spain, provided that the axe of budgetary cutbacks does not ultimately destabilise it in the short term, the medium-term prognosis is a guarded one unless its affairs are put in order in accordance with principles of the cost-effectiveness of provisions financed with public funds, and above all medication and medical technology.
The country lags two decades behind in this regard, and reforms must be applied if we wish to begin to resemble in some way the countries of Northern Europe. In Europe, examples of organisational and institutional reform undertaken in France, the UK, Sweden and Germany provide a perspective for the emulation of best practice.

The confusion between what a universal service should be, and paying for any provision, whatever the health benefit achieved, and furthermore entirely free of charge, is at grave risk of leading us towards a poor-quality, dual-track public health system. The public health system should pay for care which has value, which is effective and safe at a reasonable cost, as the only way of sustaining a key service for welfare, and one which is vital in reducing social inequality.

In the light of the considerable budgetary impact, the foreseeable tidal wave of particularly high-cost innovations of questionable benefits which lie in the pipeline of a pharmaceutical industry troubled by the erosion of patents and the downturn in R&D productivity, along with the limited transparency in decisions regarding medication, there should be no further delay in a review of the criteria employed in decisions regarding inclusion within public provision (financed or through reimbursement) and prices based on the value for money offered by treatments.

There can be no justification today for national regulators to continue, as they did until just a few months ago, to view everything new as innovative, suggesting that there is no opportunity cost, and furthermore imposing the obligation on health service administrators to be forced to offer such products almost free of charge to patients, while at the same time being accused of wasteful expenditure.

Putting affairs in order in public health care goes hand-in-hand with welfare state provision based more on knowledge and value than on ideological principles, and based more on transparency and accountability of results than on arbitrary decisions by the political and administrative elite. It is discouraging to see that right now, in breach of the regulatory framework, public health care is holding out against a structural reform of the principles of provision and administration: we will end up publicly funding almost any new treatment, whether the cost per year of life gained is highly reasonable or exorbitant.

Jaume Puig-Junoy

Jaume Puig-Junoy

Director of Health Economics programmes, Barcelona School of Management

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