Jessie Holtzman

In late November, more than 75,000 healthcare professionals gathered in Puerta del Sol, in the heart of Madrid, holding signs that read “health care cuts kill” and “public health: not for sale.”¹ Amidst new austerity measures, these employees were striking to protest a set of cuts particularly worrisome to the public health community. With the Spanish economy in crisis, the conservative government of President Rajoy announced that Spain needed to cut 10 billion Euros of health and education spending each year starting in 2012. Seven billion Euros worth of these cuts are taken from the healthcare budget.² Spaniards, and specifically members of the healthcare sector, have reacted strongly to this reduction, since it targets a key element of the prized welfare state that developed in the 1970s transition from dictatorship to democracy. While these workers have good intentions and many valid concerns, their strike hurts the patient population rather than targeting the government violating their rights.  Instead of striking, doctors and nurses should take up more productive ways of demonstrating dissatisfaction to avoid punishing the patient population for government austerity decisions.

With the current state of crisis, the Spanish government must make cuts to its extensive healthcare budget in an attempt to revive the floundering economy.  Starting in 2000, Spain became an increasingly popular country for immigration due to the generous benefits provided to immigrants. Immigration came with benefits, helping to maintain the population as the country’s growth rate fell to 1.1 children per couple. It came with costs as well, though. The country became a frequent destination for “healthcare tourism,” with residents of other European Union countries traveling to Spain for its superior healthcare procedures at low costs.  As of August 2012, the government no longer provides free healthcare services to undocumented immigrants, and “healthcare tourists” must reside within Spain for more than three months before receiving free healthcare services.³ Now, the system only provides healthcare to foreigners in cases of “grave illness or accident,” pregnancy and birth-related care, and to those younger than 18. These changes discourage non-tax-paying residents from using the healthcare system, a worthwhile policy to prevent unfair exploitation of tax-paying citizens.

However, further broad cuts to the rest of Spanish society come at a time when Spanish unemployment has climbed to dangerously high levels. Spaniards are paying an increasingly large percentage of their healthcare costs directly, while their salaries are dropping to historically low levels. Retired citizens now contribute a 10 percent copayment toward the costs of medicine, while non-retired citizens pay between 40 and 60 percent copayments, scaled to income level. Citizens now pay for wheelchairs, crutches, and splints, as well as non-urgent transport to hospitals.³

The most controversial element of the recent changes to Spanish public health financing is the Fiscal and Administrative Measures Law, implemented on January 1, 2013. This legislation aims to privatize six major hospitals in Madrid, as well as 27 non-urgent health clinics.  In addition, the measure adds a one Euro fixed supplemental charge to the cost of each prescription medication. These proposed changes sparked heated debate, with left-wing deputy Antonio Carmona saying, “Privatizing healthcare isn’t efficiency; it’s business. This isn’t law; it is a scandal.”⁴ Doctors and nurses went on strike for five weeks before the passage of the law, leading to the cancelation of more than 40,000 patient visits and a 1.74 billion Euro loss in 2012 from work stoppages. Although experts agree that the Spanish public health system needs reform, healthcare workers fear the consequences of these changes.

Spanish doctors and nurses see these changes as threatening their practices and patients. The healthcare sector claims that it protested not due to a threat to working conditions or privileges, but rather for the right of everyone to have access to quality healthcare. Doctors fear that the changes jeopardize the delicate balance of healthcare expenditure, quality, and benefit in favor of a better business arrangement. They point to claims by government administrators that hospital expenditures per capita will decrease from 600 Euros to approximately 450 Euros.³ Where the measure calls for cuts in treatments with lower proven efficacy, doctors fear that eliminating procedures to save money could reduce quality of care and ease of access.

Yet, the extended striking of doctors and nurses, “la marea blanca,” raises questions about the obligation of health professionals to provide quality healthcare. This essential service sector has a right to negotiate for acceptable working terms, but patients also have a right to expect uninterrupted access to care.  The strike’s effect of stopping all non-urgent care challenges the patient-physician contract, which requires that physicians act responsibility and provide continuing care to patients. Doctors have a fundamental obligation to treat their patients to the fullest extent possible, so alternative methods of manifesting dissatisfaction toward the government would be preferable. However, effective non-striking options require fundamental trust between the two parties, which is currently absent in Spain. Historically, Spaniards do not trust the government due to the high levels of corruption and nepotism that lead to concerns about the motives behind government decisions. Nevertheless, given the ethically dubious nature of healthcare professionals striking, the government and the unions must put aside their differences to achieve a feasible level of budgetary cuts in this time of dire economic crisis.

The associated doctors of one of the healthcare unions issued a statement saying, “We need the patients to know that we do this for them, because we know the depravity of the systems of incentives in private healthcare. It is a question of responsibility.”⁴ The doctors claim to act out of care for patients rather than interest in their own compensation. Indeed, by striking, union workers accept fines and decreased salaries, in return for calling attention to what they see as unfairly imposed austerity measures.  While some patients may agree with the doctors and support the strikes, though, the health care strikes harm the patient population, with the cancelation of thousands of procedures. Striking on behalf of the patient population surely makes a public statement about the dissatisfaction of physicians and nurses, but it also jeopardizes the goal of the public health system to “ensure the conditions in which people can be healthy.”⁵ Healthcare workers are essential to society, and as such, their union rights cannot be ignored. Ultimately, a doctor’s right to strike cannot, and should not, be entirely eliminated. Nevertheless, this does not mean that a strike is the best option.

 

References

1. Thousands protest austerity measures in Spain. RT [online]. December 18, 2012. Available at: http://rt.com/news/spain-union-protest-mass-228. Accessed December 28, 2012.
2. Day, Paul. Spain seeks health care cuts as crisis deepens. Reuters [online]. April 18, 2012. Available at: http://www.reuters.com/article/2012/04/18/us-spain-health-idUSBRE83H0LX20120418. Accessed December 9, 2012.
3. Los recortes sanitarios, uno a uno. El Mundo [online]. April 25, 2012. Available at: http://www.elmundo.es/elmundo/2012/04/24/espana/1335249973.html. Accessed December 14, 2012.
4. Sevillano, Elena. El bastion de la ‘marea blanca.’ El Pais [online]. November 10, 2012. Available at: http://ccaa.elpais.com/ccaa/2012/11/10/madrid/1352585971_ 718417.html. Accessed December 12, 2012.
5. The Future of the Public’s Health in the 21^st Century. Institute of Medicine of the National Academies: November, 2002.