Reform of primary health care: the case of Spain

ELSEVIER
Health Policy 41 (1997) 121-137
Reform of primary health care: the case of Spain
Itziar Larizgoitia a,*, Barbara Starfield b
b Department
a Coopers and Lybrand
(Health
Group), Escoles Pies 102, 08017 Barcelona,
Spain
of Health Policy and Management,
Johns Hopkins
School of’ Hygiene
and Public
624 N. Broadway,
Baltimore,
MD 21205,
USA
Health,
Received 24 March 1997; accepted 14 April 1997
Abstract
Different approaches to health reform are proposed in many countries to overcome
inefficiencies in care delivery. This paper assessesan incremental reform initiated in Spain 10
years ago, which sought to improve the efficiency of the entire health system through changes
in the organization and delivery of primary care. In this study, aspects of accessibility,
comprehensiveness, longitudinality and technical quality of reformed versus unreformed care
were assessedfor respondents to a household interview survey conducted in the Basque
Region of Spain in 1992. According to this study, aspects of care such as longitudinality and
technical quality seemed improved with the reform, whereas other aspects such as accessibility and comprehensiveness remained unchanged. The authors conclude that system related
characteristics (more associated with access and comprehensiveness) may be impeding the
achievement of the goals of the reform and argue that attempts to encourage more autonomy
of care delivery may be required. 0 1997 Elsevier Science Ireland Ltd.
Keywords:
Health reform; Primary care; General practice; Quality; Interview survey; Spain
* Corresponding
author. Tel.: + 34 3 4181116; fax: + 34 3 4189447; e-mail: [email protected]
016%8510/97/$17.00 0 1997 Elsevier Science Ireland Ltd. All rights reserved.
PIISO168-8510(97)00017-1
122
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1. Introduction
The health care systems of many countries are undergoing reform. The need for
greater efficiency and an increasing demand for responsiveness to customers’ needs
provide the imperatives for reform and makes primary care the central element of
it [l]. In many cases, drastic changes in organization of health systems are required
to achieve a focus on primary care [2,3].
The Spanish health system reform effort exemplifies a reform directed at improving the efficiency of the health care system by improving the delivery of primary
care [4]. This reform is proceeding incrementally, with varying degrees of change in
different areas, thus presenting the opportunity to perform an evaluation of the
impact of reorganization on various aspects of health within a country. The
purpose of this paper is to describe such an effort.
2. The Spanish primary care reform
The Spanish reform of primary care was initiated in 1984 [5]. It focused on
primary care in concert with the principles of the Conference of Primary Care at
Alma Ata, wherein primary care includes the maintenance of health and community participation [6]. The new focus was to be characterized by team work as the
mode of practice and by an intention to increase the accessibility, comprehensiveness, coordination of care and patient’s satisfaction, rather than solo practice and
episodic care as delivered previously [7]. It was accompanied by an infusion of
resources, including newly trained family physicians [8]. The principal features of
the reform as compared to the traditional model are shown in Table 1.
More than 10 years after the enactment of the reform, its implementation has
been incomplete and a systematic assessment of its outcomes has not been performed. There are some reports of increased satisfaction [9,10] and of better
management of chronic diseases [ll-141; other reports show no significant improvements [15,16]. The uncertainty about the reform’s outcome in view of its
initial expectations have given rise to an intense debate [17-191 about its future.
3. Analytical framework: primary care and its assessment
The conduct of this study depended upon a conceptualization of primary health
care in a manner that permitted its evaluation. Primary care has been defined as a
philosophy and a way of arranging services in with the focus on maintenance of
health and on community participation
[20]. This research used a conceptual
framework originally developed by Starfield [21], who described primary care as
being characterized by four unique attributes: front-line care, comprehensive,
allowing for a longitudinal relationship between provider and patient, and being the
coordinator for all the care provided. She further proposed measuring the attaintment of these attributes by assessing their achievement through aspects of structure,
I. Larizgoitia,
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123
process and outcomes. In this study we have added a fifth attribute: technical
quality, i.e. the provision of medically sound and appropriate care. We measured
intermediate outcomes directly from the medical process rather than final outcomes, since the latter are multifactorial and difficult to attribute to any aspect of
medical care [22,23]. The level of achievement of these five attributes may be
defined as the level of the ‘quality of care’ performed.
This study assesseswhether the reformed model of the Spanish primary care has
achieved higher levels of quality of care as compared to the traditional model. Four
specific aspects could be assessed from the data source used: (i) level of access; (ii)
comprehensiveness of care; (iii) likelihood of a longitudinal relationship; and (iv)
technical quality of care.
4. Methods
4.1. Population
The scope of this study is restricted to the Basque Country, one of the
Autonomous Regions of which Spain is politically and administratively organized
[24]. The Basque Health Service (Osakidetza/Servicio Vasco de Salud) is the
decentralized component of the National Health Service that provides health care
Table 1
Major features of the reformed model as compared to the traditional
Reformed model
model of primary care delivery
Traditional
Area of influence
Geographically defined population
(the ‘health zone’)
Place of delivery
Health care centers: new physical and
functional structures to perform PHC
activities
Team work
Solo practices
Multidisciplinary team, formed by fam- Physicians and nurses with no
specific training in primary care
ily physicians, nurses, midwives, pediatricians, and others under the direction
of a medical coordinator
Delivery of care at a health care center Assistance of daily patient’s demand,
or at home, coordinated with other
at the facility or at home. Focus on
curative medicine
levels of care, prevention, health promotion, education, needs assessment
and evaluation of activities
Episodic care
Longitudinal, continuous, integrated
and comprehensive care, based on team
work of all professionals
2,5 daily shift, plus time needed to
40 h per week plus time needed to
cover emergency care
cover emergency care
Work organization
Staff
Content of care
Attributes of care
Schedule
base
model
No population defined initially. With
time it also included the ‘health
zone’
Old ambulatory centers, no admissions facilities, nor archives
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in the region [25]. By 1991, coverage by reformed service organizations reached
almost 55% of the population although there were large differences across geographical areas [26]. Primary care physicians are salaried employees who are linked
to individual consumers by the Health Service; consumers may change providers if
desired.
4.2. The study
This study used a household interview survey conducted in 1992 by the Health
Department of the Basque Government [27]. The survey collected consumer’s
reports on health services utilization and on consumer satisfaction. It was based on
a regional probability sample of the civilian non-institutionalized
population of the
Basque Region, and used a multistage probability sampling process to select 4000
households corresponding to 13 278 individuals. Face to face interviews were
administered by trained interviewers with at least one adult member of the
household.
Dependent variables were developed to respond to each of the specific objectives
of this study. Several covariates that were expected to have an effect on the
dependent variables were also identified from the survey. Table 2 shows all
variables used in this study, indicating their corresponding primary care attributes,
measures and operational definitions used.
Social class was classified into five categories based on the household head’s
occupation as reported in the survey. It ranged from professionals, or employers
(class I) to manual unskilled workers (class v). For a few cases where occupation
was not available, social class was derived from the household head’s stated
educational level. Household head’s social class was assigned to all household
members.
The main independent variable was the type of primary care (reformed or
traditional) each survey respondent was receiving. Type of primary care was not
available for survey respondents on an individual basis. It was estimated based
upon the area of residence by means of data provided by the Regional Health
Service that indicated the number and type of physicians’ contracts by ‘health
zone” [28] and by municipality. Small areas for which data were available were
defined as either the municipality or the health zone, whichever was smaller in
terms of population size. The ratio of primary care physicians (general practitioners
and pediatricians) working for the reformed model within small areas divided by all
primary care physicians in the same area was calculated to determine the predominant type of care in each area. Each area was classified according to the
penetration of the reformed model from ‘0’ (if there were no physicians working in
the reformed model) to ‘1’ (having only physicians of the reformed model). This
proportion was linked to survey respondents according to their residence.
’ Health
zone
is the smallest
subdivision
of the Health
Service,
corresponding
to KKK-25
000 persons.
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Table 2
Variables, measures and operational definitions used in this study
Attribute
Dependent
Variable
Measures
Operational
Accessibility
Days until doctor visit
Time waiting at
clinic
Proximity to
clinic
Clinic working
hours
Satisfaction w
access
Use of emergency care
Use of hospital
care
Blood pressure
test
Flu immunization
Mammogram
Percent visited on same day
variables
Access
Consumer’s opinion
Adequacy of
specialty care
Comprehensiveness
Longitudinality
Technical
quality
definition
Use of preventive
care
Pap smear
Use of regular source Extra private
of care
insurance
Visit length
Length visit
Percent waited less 15 min
Percent judged center is close orvery
close
Percent judged schedule very convenient
Percent were very satisfied with access
Percent used emergency care in 1 year
Percent were hospitalized in 1 year
Percent blood pressure checked in 1
year
Percent immunized in 1 year
Percent
years
Percent
Percent
surance
Percent
getting a mammogram in 3
getting a pap smear in 3 years
purchase extra private invisit lasted more than 10 min
User satisfaction
Composite scale
Percent were very satisfied with visit
Independent
variable
Type of Care
Type of Care
Reformed MDs/all MDs by small
area
Intervening
variables
Demographics
Age categories
Gender
Socioeconomic status Social class
Location
Migrant status
Health status
Chronically ill
Use of services
Insurance
Gender categories
Social class categories (I through V)
Urban/rural
First generation/longer term residents
Percent having at least one chronic
disease
Self-perception
Percent reporting good or very good
health
Frequency of use Percent visiting (O/l-2/mare 2) times/
year
Private Insurance Percent purchase extra private insurance
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The analysis was restricted to individuals residing in areas that were known to
either have all reformed physicians or all non-reformed physicians, in order to
diminish misclassification errors. Survey respondents falling into any of these two
categories comprised 44% of the total survey sample. (A sensitivity analysis was
performed to assess the sensitivity of the results to specific operational definitions of
the ‘type of care’, by re-categorizing reformed areas as those that had more than
65% of reformed physicians and traditional areas as those that had 35% or less.
Survey respondents that fell into these categories comprised 71% of the total survey
sample.)
The unit of analysis was the individual or survey respondent. Multivariate
analysis including logistic regressions for each of the dependent variables were
performed. The coefficient of determination R”-, a summary statistic that indicates
the proportion of variance explained by the model, was calculated through a
generalization of this coefficient to general regression models [2912. All dependent
variables in the analysis were dichotomized to assume the form of binomial
probability for logistic regressions. The general model that was used in the analysis
was the following:
lo&bdJ
= log(PdJl -PA
= /& + /I1 agegroup + p2 gender + p3 health status
+ /I4 insurance status + p5 frequency of using services
+ p6 social class + a, location + /3* migrant status
+ /I9 type of care
Data analysis was performed using the statistical software package SUDAAN,
6.40 [30]. This is a statistical package specifically designed to analyze data from
complex surveys and from other studies involving clustered data 1311. All data
management and exploratory data analysis was performed using the statistical
software package SAS, 6.04 for PC [32].
5. Results
5.1. Study sample
The study included 5854 individuals, representing 44% of the total survey, whose
residence was located in areas with only one type of care (reformed or traditional).
This criterion led to the greater likelihood of including rural areas and areas where
pediatricians took care of children, since other types of areas were more likely to
have a mixture of types of care. As a consequence, there were relatively more
children, rural persons and longer term residents in the study sample. These rural
’ R2 = (1 - exp( - 2/n(l(F) - I(O))))/(l - exp( - 2/n1(0))), where l(F) is the log likelihood
model and l(0) is the log likelihood of the null model.
of the fitted
I. Larizgoitia, B. Starfield /Health Policy 41 (1997) 121-137
121
areas, as well as areas with children and upper class residents, were more likely to
have services of the traditional type. In contrast, the urban areas included in the
study, which also had more recent migrants and more lower social class residents,
were more likely to have the reformed model (Table 3).
5.2. Differences in access across type of care
Two aspects of access were measured: (a) accessibility to the clinic; and (b)
consumer opinion of accessibility. Accessibility, in turn, was measured by two
items: (i) the likelihood of seeing a doctor the same day of request; and (ii) the time
waiting at the clinic to see a doctor. The consumer’s opinion of accessibility was
measured by (i) the reported proximity to the clinic; (ii) convenience of office hours;
and (iii) satisfaction with waiting time and the appointment system. In addition, the
rate of hospitalizations and of emergency care were measured to assess the
manifestations of compromised access.
No clearly significant difference was found for most of the variables measuring
access except for the variable measuring waiting times at the clinic. However,
waiting times were reported to be shorter in reformed areas especially among the
lower social class but the chronically ill reported significant longer waiting times in
reformed areas independent of social class.
An unclear differential effect of the reform across the social class gradient seemed
to occur for variables measuring the consumer’s opinion of accessibility. The lowest
social class showed more favorable opinion regarding this dimension while the
upper classes were less satisfied, but the magnitude of this effect was not clear since
confidence intervals were wide (Table 4).
Use of emergency care seemed to be similar across type of care, while hospitalizations seemed to be less frequent among migrants in reformed areas (Table 4).
5.3. Differences in comprehensiveness
No difference was observed for any of the four preventive measures considered in
this study to represent comprehensiveness (influenza immunizations, blood pressure
measurement, pap smear and preventive mammogram).
5.4. Differences in the rate of purchasing additional private insurance
The purchase of additional private insurance was used as a proxy measure of
longitudinality,
assuming that the greater the perceived need to consult private
physicians the weaker the association with the health service physician and,
therefore, the less likely the establishment of a long term relationship. There was a
significant difference in the rate of purchasing additional private insurance, with
lower likelihood in reformed areas as compared with areas with traditional care
(Table 4).
128
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Table 3
Demographic
and health
B. Starfield
/ Health
Policy
41 (1997)
care characteristics
of the study
sample
and
121-
137
of the entire
survey
Age
O-14
14-24
25-44
44-64
65+
18.9
17.4
31.0
21.9
10.6
(16.6;
(15.8;
(29.2;
(20.3;
(9.2;
21.2)
19.0)
31.8)
23.5)
12.0)
42.1*
11.8*
20.4*
15.4*
10.2*
(38.4;
(10.2;
(18.3;
(13.8;
(8.5;
45.8)
13.4)
22.5)
17.0)
11.7)
17.2
16.9
30.1
23.3
12.4
(16.4;
(16.2;
(29.2;
(22.5,
(11.7;
18.0)
17.7)
30.9)
24.1)
13.2)
Gender
Males
Females
50.0
49.9
(48.7;
(48.6;
51.3)
51.2)
49.6
50.3
(47.9;
(48.7;
51.1)
51.9)
49.1
50.8
(48.5;
(50.2;
49.8)
51.5)
Social class
I (higher)
II
III
IV
V (lower)
6.5*
8.7
11.2
43.6
29.7*
(4.7;
(6.9;
(9.2;
(39.8;
(26.6;
6.5)
10.5)
13.2)
47.3)
32.8)
13.5
12.1
13.7
43.5
17.2*
(10.9;
(9.7;
(11.4;
(39.9;
(14.6;
16.1)
14.3)
16.0)
47.1)
19.8)
11.3
9.6
13.9
41.4
23.7
(10.1;
(8.6;
(12.7;
(39.6;
(22.2;
12.5)
10.6)
15.1)
43.2)
25.1)
69.7*
30.2*
(67.4;
(27.9;
71.9)
32.4)
85.6*
14.4*
(83.6;
(12.4;
87.6)
16.4)
73.5
26.4
(72.6;
(25.4;
74.6)
27.4)
90.4
9.6
(86.7;
(5.9;
94.0)
13.3)
10.5
29.5*
(80.8;
(24.7;
90.4)
34.2)
89.4
10.5
(87.7;
(8.9;
91.0)
12.2)
69.9
(68.1;
71.7)
69.1
(67.6;
71.7)
69.2
(68.3;
70.1)
18.2
(16.8;
19.6)
17.8
(16.2;
19.4)
18.9
(18.2;
19.6)
11.9
(10.6;
13.1)
12.5
(11.1;
13.9)
11.8
(11.1;
12.4)
10.4
49.3
30.7
8.2
1.3
(8.2;
(45.7;
(27.6;
(6.5;
(0.5;
12.6)
52.8)
33.8)
9.9)
1.3)
11.2
52.0
28.4
7.4
0.9
(7.9;
(46.9;
(23.9;
(5.2;
(0.2;
14.4)
57.1)
32.9)
7.3)
0.9)
10.3
50.1
31.0
7.4
1.2
(9.2;
(48.3;
(29.4;
(6.5;
(0.85;
11.4)
51.8)
32.6)
8.3)
1.6)
28.8
35.4
(25.8;
(33.6;
31.7)
37.5)
26.6
37.2
(24.4;
(34.9;
28.8)
39.4)
27.4
36.8
(26.4;
(35.7;
28.4)
37.8)
35.7
(33.6;
35.7)
36.4
(34.0;
38.8)
35.8
(34.7;
36.8)
Migrant
status
Locals
First generation
Location
Urban
Rural
Health status
No chronic
disease
One chronic
disease
Two or more
Perceived
health
Very good
Good
Regular
Bad
Very bad
Frequency
of use
No visits
One or two
visits
Two or more
Total respondents
*Difference
distribution).
3234
in proportion
2620
statistically
significant
13 278
at the 0.05
level
(as compared
to the entire
survey
time
perceived
hours
satisfied
Clinic
Office
Very
Without
convenient
a year
private
insurance
with care
insurance
insurance
care within
within
10 min
Satisfaction
With private
of request
with
a year
access
or very
15 min
to be close
Visit
longer
day
and adjusted
or satisfied
very
private
emergency
same
less than
Additional
Used
Hospitalized
doctor
Waiting
estimates
Seeing
Table 4
Unadjusted
close
odds
ratios
for
No
disease
disease
disease
Chronically
0 No
l
0 No
35.2 (1.8)
l Chronically
38.6 (3.2)
9.1 (0.9)
10.1 (0.6)
6.5 (0.4)
24.4 (1.5)
29.4 (2.8)
34.1 (2.9)
l
50.4 (2.9)
0 Chronically
ill
ill
ill
percent
Reformed
49.1 (3.2)
variables
dependent
(SE)
(2.2)
30.3 (2.4)
0 Migrants
0 No migrant
0 Migrants
0 No migrant
0 Migrants
l No migrant
l Migrants
l No migrant
28.1 (3.6)
14.1 (0.63)
10.5 (0.6)
5.3 (0.5)
0 Migrants
0 Locals
28.2 (2.5)
0 Class I. II.
0 Class IV
0 Class V
30.3 (1.8)
0 Class I, II,
0 Class IV
0 Class V
42.6
56.3 (3.5)
0 Class
0 Class
0 Class
0 Class
0 Class
0 Class
62.9 (3.7)
percent
traditional
III
III
I, II, III
IV
V
I, II, III
IV
V
versus
Traditional
in reformed
(SE)
areas
0.95
0.51
0.43
0.24
3.59
1.97
1.70
0.94
1.90
0.74
1.15
0.72
1.32
0.74
0.12
1.42
1.06
0.64
1.68
1.14
0.23
0.38
0.88
0.73
1.19
2.72
0.86
Adjusted
OR”
(0.38;
(0.17;
(0.14;
(0.08;
(1.95;
(1.15;
(0.92;
(0.60;
(1.14;
(0.53;
(0.94;
(0.45:
(0.97:
(0.44;
(0.29;
(0.73;
(0.62;
(0.37;
(0.68;
(0.81;
(0.09;
(0.19;
(0.32;
(0.34;
(0.64;
(1.06;
(0.54;
CI,,,
2.58)
1.43)
1.30)
0.65)**
6.62)**
3.39)**
3.12)*
1.45)
3.17)**
1.03)*
1.41)
1.15)
2.08)*
1.27)
0.77)**
2.77)
1.80)
1.09)*
3.22)
1.61)
0.55)**
0.78)**
2.36)
1.53)
2.22)
6.95)**
1.38)
0.22
0.19
0.66
0.54
0.84
0.35
0.25
0.09
0.11
0.09
R2
130
5.5. Dfferences
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/Healrh
Policy
41 (1997)
121-137
in the technical quality of care
The technical quality of care was measured by two variables: (a) length of visit;
and (b) patient’s satisfaction with the care received. Patient’s satisfaction, in turn,
was measured through a composite scale that included items related to: (a) physician’s
interpersonal skills; (b) nurses’ interpersonal skills; (c) visit length and (d) the
completeness of information received.
Significant differences were found for both variables. Length of visits were
significantly greater in reformed areas (mean, 11.57 min; SE, 0.52) as compared with
traditional areas (mean, 10.15 min; SE, 0.43). Satisfaction with care was also higher
in reformed areas for at least certain groups of respondents; the chronically ill,
migrants and persons with no private insurance gave higher ratings with the care
received. This effect is more clearly observed in persons with at least two of these
characteristics, as shown in Table 4. Conversely, persons having private insurance
were less satisfied in reformed areas than persons without insurance.
5.6. Sensitivity analysis
The sensitivity analysis included areas with more than 65% of reformed physicians
(as ‘reformed’) and with 35% percent or less of reformed physicians (as ‘traditional’).
The resulting sample included 9470 survey respondents or more than 7 1% of the entire
survey. Results of the sensitivity analysis were consistent with those obtained in the
main analysis (Table 5).
6. Discussion
This study assessessome of the achievements of an organizational model that was
intended to improve the existing delivery of primary care by adopting a defined strategy
for providing it. The underlying philosophy that gave rise to the reform assumed that
a strong and holistic primary health care would led to better care, higher satisfaction,
and greater efficiency. This study suggested that benefits in certain aspects of care
were achieved, but did not show decisive improvements for the reformed model across
all aspects measured, thus pointing to incomplete achievements of the reform.
It maybe, however, that the observed lack of differences are a result of weaknesses
of the study. The absence of specific information concerning the performance of
primary care led to the use and secondary analysis of an existing data source (the
most recent available in the region). This instrument may not have been sensitive
enough to discern the outcomes of interest. Furthermore, some important aspects of
the reform, such as coordination of care or community participation, could not be
measured with the data sources used. The lack of information concerning these two
major goals of the reform may understate its real accomplishments. Although
interpretation of the results should consider these limitations, the outcomes analyzed
provide a coherent set of information on many of the principal attributes of primary
care (first line, longitudinality,
comprehensiveness and technical quality). A more
precise assessment of primary care would have required the availability of
I. Larizgoitia,
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41 (1997)
121- 137
131
specific measures, as has been proposed [21]. Potential misclassification of the
variable ‘type of care’ is also a concern. Estimation of the type of care at the
individual level was based on an aggregated weight, thus introducing the risk of
misclassification [33]. However, the use of small areas to classify respondents, and
the selection of areas with only one type of care should have diminished this risk
[34,35]. Moreover, the sensitivity analysis supported the minimization of significant
misclassification. Any remaining misclassification would have led to loss of power
and reduced ability to detect differences between the types, since the misclassification would have been randomly distributed across both groups [36].
Despite these limitations, the main results of the study are consistent with many
earlier observations, thus supporting their coherence. Earlier studies also found
inadequate perceived accessibility within the reformed centers [10,37], a surprising
finding since the reform was characterized by increased availability through construction of new centers, more comfortable facilities and longer working hours
[9,38]. These benefits should have been reflected in the study. Others have documented the fact that the reform was initially implemented in areas which were
previously less well served [9,39]. Perhaps the resulting similarity in access indicates
considerable improvement in areas that were at increased disadvantage prior to the
reform. However, the needs of upper and middle class customers have not been
satisfied, since only persons of lowest social class reported better access in the
reformed areas. Thus, the reform seems to have improved the equity of distribution
of health services in those areas where it has been fully implemented.
Apparent lower accessibility for the chronically ill in the reformed areas may be
a result of differences in the scheduling and content of special clinics held for these
patients, which may be at times less convenient for them than was the case in the
prior traditional system. Since almost half of all consultations in reformed areas are
devoted to the chronically ill [40], the overall findings on accessibility would have
been heavily influenced by them. Given that care for the chronically ill may be
different across models of care, comparisons based on unspecific measures (such as
waiting times) should be taken with caution.
The absence of perceived improvements in comprehensiveness of care, as measured by receipt of the four preventive interventions, is in contrast with the purpose
of the reform and with other reports [41], and suggests the need for reconsideration
of the role of primary care in preventive activities. Only one of the activities
evaluated (blood pressure measurement) relies upon the behavior of the primary
care practitioner. The other three depend more on factors external to primary care;
influenza immunizations are actively promoted by the Regional Health Service as a
public health activity [42], and the other two (pap smears and mammogram) are
generally performed on referral from primary care rather than by the primary care
physician. Receipt of these services may be heavily influenced by care-seeking
behavior of patients [43,44] or by insufficient accessibility to secondary care [45],
but the physician’s advice and referral is an important predictor of their use [46,47].
The apparent improvements in perceived need for private insurance, visit length,
and satisfaction with care are consistent with those seen in other studies [9,37,48].
The fact that increased satisfaction with care was concentrated among the chroni-
Compromised
access
Seeing doctor same
day
Waiting for less 15
min
Accessibility
Emergency care
Hospitalizations
Satisfaction with access
Proximity to clinic
Convenience office
hours
Variables
Dimension
Chronic patients
0 Non chronic patients
l
Interactions
0.86)**
2.16)
1.53)
1.52)
3.66)*
1.60)
1.70)
0.83 (0.55; 1.22)
1.10 (0.86; 1.42)
1.03 (0.86; 1.23)
0.72 (0.45; 1.15)
1.32 (0.97, 2.08)*
1.15 (0.94; 1.41)
0 Migrant
0 No migrant
0.12 (0.29; 0.77)**
1.42 (0.73; 2.77)
0.68 (0.47; 0.99)**
1.25 (0.77; 2.05)
(0.26;
(0.45;
(0.46;
(0.55;
(0.98;
(0.96;
(0.76;
0 Class IV
0 Class V
0.48
0.99
0.83
0.92
1.89
1.24
1.13
0.94 (0.63; 1.39)
1.57 (0.97; 2.54)*
0.62 (0.42; 0.93)**
0.78)**
2.36)
1.53)
1.45)*
4.26)**
1.61)
1.80)
0.44 (0.22; 0.85)**
0.62 (0.43; 0.87)**
0 Class IV
0.64 (0.37; 1.09)*
0 Class V
1.68 (0.68; 3.22)
0 Class I, II and III 0.74 (0.44; 1.27)
0 Class I, II and III
(0.19;
(0.32;
(0.34;
(0.98;
(1.72;
(0.81;
(0.62;
0.38
0.88
0.73
1.19
2.72
1.14
1.06
IV
V
I, II and III
IV
V
0
0
0
0
0
Class
Class
Class
Class
Class
0.23 (0.09; O.SS)**
0 Class I, II and III
0.86 (0.54; 1.38)
Sensitivity analysis adjusted
OR”
of obtaining the dependent variable in reformed versus
Study sample adjusted
OR”
Table 5
Comparative results of the study and the sensitivity analysis: adjusted odds ratios for the likelihood
traditional areas
With private
insurance
With no private
insurance
l
l
a ORs were adjusted by all covariates included in the final model.
* Marginally non-significant at the 0.05 level.
** Statistically significant at the 0.05 level.
Visit length
Satisfaction with
care
Technical Care
ill
0 Migrant
0 No migrant
No chronic sick
0 Migrant
0 No migrant
0 Migrant
0 No migrant
No chronic sick
0 Migrant
l No migrant
Chronically ill
Chronically
2.41 (1.43; 4.01)**
1.52 (1.01: 2.29) **
1.77 (1.10; 2.82)**
1.12 (0.80; 1.56)
1.70 (0.92; 3.12)*
0.94 (0.60; 1.45)
0.73 (0.33; 1.59)
0.46 (0.23; 0.91)**
0.43 (0.14; 1.30)
0.24 (0.08; 0.65)**
3.59 (1.95; 6.62)**
1.97 (1.15; 3.39)**
1.00 (0.44; 2.27)
0.63 (0.30; 1.59)
1.76 (1.18; 2.63)**
0.95 (0.74; 1.21)
0.87 (0.68; 1.10)
1.18 (0.85, 1.63)
0.95 (0.68; 1.35)
1.19 (0.87; 1.66)
0.95 (0.38; 2.58)
0.51 (0.17; 1.43)
1.90 (0.53; 1.03)**
0.74 (0.53; 1.03)*
0.85 (0.61; 1.18)
1.09 (0.70; 1.70)
1.01 (0.63; 1.60)
Blood pressure
Pap smear
Mammogram
Extra insurance
1.09 (0.68; 1.74)
Flu vaccination
Longitudinality
Comprehensiveness
134
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B. Starjield
/Health
Policy
41 (1997)
121-137
tally ill supports the notion of improved care for these patients [49,50]. Interestingly, satisfaction with care was negatively associated with having private insurance
in reformed areas, suggesting a tendency of the less satisfied, to buy additional
insurance. In traditional areas, the relationship was positive perhaps because these
persons may find a complementary balance between the two systems.
Some critics [51] have suggested that implementation of the reform may have
been too timid and slow. Expansion of the reform in the Basque Region occurred
only a year before the survey used in this study was carried out [52]. Thus, time of
exposure to reform may have been too short to have exerted any meaningful impact
on the characteristics considered.
Overall, the pattern of findings suggests that the reform improved those attributes of care that are more related with physician behavior (as with improved
care for the chronically ill) than to system organization, such as access or comprehensiveness. Furthermore, certain characteristics, such as regulations, health policies and labor policies, may be influencing the implementation of the reform. For
example, accessibility of services may depend more heavily on centralized regulations and labor policies than on decisions made by individual health centers in
response to patients’ needs in the local area. Comprehensiveness depends at least as
much on policy decisions about where certain services should be performed than on
whether physicians actually perform the indicated procedures. The lack of responsiveness to consumer interests by centralized public systems has been noted in
several countries of Europe that now are undergoing health system reform [2,3].
The bureaucratic rigidity that characterizes the micro-management
of the health
care institutions in such systems may play a role in the apparent incompleteness of
primary care reform, as has been suggested [53].
The Basque Health Service is currently in the process of implementing improvements in the efficiency of health services. These try to establish a regulated market
environment where providers compete for patients. It is expected that these changes
will be beneficial for patients in that competition will encourage provider’s autonomy and flexibility in the management of health services to better respond to
consumer’s needs [54]. Although, they have not yet had a significant impact in the
organization of primary care, the challenge will be to accomplish this without
sacrificing the improved benefits that seems to have been achieved through the
reform examined. The risk of developing forms of care delivery detrimental to the
achievement of primary health care, as has been observed in settings that focus
primarily on maximizing efficiency and cost containment [55], needs attention in
subsequent reform efforts.
Acknowledgements
The authors are grateful to the staff of the Departamento
de Sanidad de1
Gobierno Vasco, Osakidetza/Servicio Vasco de Salud and EUSTAT/Instituto
Vasco de Estadistica who supplied the data and gave permission for its use. We are
also grateful to Cecilia Anitua, Santiago Esnaola and Angeles Iztieta for their
I. Lmizgoitia,
B. Star$eld/Health
assistance. Thanks to the friendly
Rohde, Richard Morrow, Vicente
study. Ruth Hurd who made the
Dean Roehl for carrying out the
Policy
41 (1997)
121-137
135
collaboration of Drs Jonathan Weiner, Charles
Navarro and Ana Diez who greatly improved the
writing of this paper possible, and Rob Reid and
study.
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