FACT SHEET n.11 – Gennaio 2020 – Di Stella Christou, Scuola Normale Superiore
Primary care sits at the heart of the Alma-Ata Declaration, inspiring the development and organisation of the Southern European Health Systems and their subsequent transformation into National Health Systems. In principle, primary care aims for a wide population coverage, based on disease prevention and life quality improvement, and it is meant to serve as the first, yet holistic, point of contact of the patient with the healthcare system.
In this spirit, primary care is the backbone of any National Health System (NHS). However, despite the initial convergence between the four models, primary care in Spain, Italy, Portugal and Greece has followed different trajectories concerning the three key dimensions of financing, provision and coverage.
Spain’s NHS is mostly publicly funded and owned, and it has a universal scope. It is a decentralised health system around Spain’s Autonomous Communities (ACs) and respective Health Services. Primary care in the Spanish context is central to the operation of the NHS, as access is guaranteed by law while being a necessary step for referral to any other level of care. It is organised on the basis of multidisciplinary health teams, staffed by General Practitioners (GPs) and family doctors, nurses, dentists, social workers etc. Despite the existence of differences across the ACs, Spain’s primary care enjoys wide approval (see the comparative figures in figure 2 below), with 86% of patients declaring having received good or very good care, according to the national Health Barometer (2016)2. The Health Act for the establishment of the NHS actively supports and encourages citizen and community participation in health decision making and it is guaranteed by health councils.
Italy’s NHS is funded mainly through national and regional taxation, and it operates of the principle of universal coverage. It is a decentralised health system, where decisions and goals put forward at the national level are managed and implemented by regional health departments. GPs and pediatricians are the central figures in the primary care sector, serving as ‘gatekeepers’ to different care levels. Regional differences and economic disparities are the main obstacles to reaching equality and harmonisation of the NHS nationally, both in terms of provisions and innovation. In primary care, efforts to modernise, integrate and enrich services with multidisciplinary health teams and ensure continuity with both health and social services has resulted in different configurations across regions.
Portugal’s NHS is also mainly funded through general taxation, although private contributions amount to 35% of the total health expenditure3. Following a similar decentralised configuration, the Ministry of Health earmarks funds for the regional health authorities to finance primary care and certain programs. Primary care is publicly funded and managed by the ACES (Agrupamentos de centros de saúde) – groups formed by the integration of community care and public health units in 2008. These units work with teams of medical professionals, mostly focusing on family health and disease prevention. Innovation currently moves in the direction of vertical integration, aspiring to connect health to social support services as well as primary to higher levels of care, through the creation of Local Health Units.
Greece’s NHS is partly financed through the public budget and partly through insurance funds. Importantly, however, private contributions in the form of out-of-pocket payments add up to 41% of the total health spending4. Albeit universalistic in principle, this funding configuration is reflected in the way primary care is both provided for and its scope; as until 2017, half of the centres providing primary care belonged to the Health Ministry and the rest to insurance funds. As such, continuity of care was hampered and coverage was not guaranteed, due to its dependence on the employment status of the patient. Plans and proposals to restructure and universalise primary care both in terms of geographical distribution and quality of services have been in the national agenda since the establishment of the NHS in 1983. This is further complicated by the lack of any referral system assuring continuity, integration and coordination of care across different levels, units and regions. The recent economic crisis and concomitant austerity policies took a toll on the health of the population, calling for an urgent healthcare reform, especially on the level of primary care. Law 4486/2017 included the restructuring and decentralisation of primary care, through the introduction of family doctors and the incremental establishment of Local Health Units providing welfare and healthcare services to the population.