Evaluating mental health care and policy in Spain.

BACKGROUND: The reform and expansion of mental health care (MHC) systems is a key health policy target worldwide. Evidence informed policy aims to make use of a wide range of relevant data, taking into account past experience and local culture and context.

AIMS: To discuss the organisation, provision and financing of MHC in Spain visa vis the goals of recent psychiatric reforms.

METHOD: We draw upon existing literature, reports and empirical data from regional and national health plans, as well as European reports pertinent to Spain. In addition we have made use of iterative discussion by an expert panel on the features of Spanish MHC services, namely its history, characteristics and determinants in comparison to reforms in other European health systems.

RESULTS: In contrast to most other European health systems, the Spanish case reveals that political regional devolution leads to a greater heterogeneity in MHC systems, with some of the 17 autonomous communities (ACs) or region states that make up the country moving more rapidly to full de-institutionalisation alongside coverage expansion and policy innovation. There remains a lack of specific earmarked budgets for MHC at a time of under-funding. There has been an imbalance in MHC reforms, with more focus on the principles underpinning the process of de-institutionalisation and less on the actual development of alternative community based mental health services. Moreover there has been a lack of monitoring of the reform process. Common to other countries, attempts to develop a more informed evidence policy have been hampered by a dislocation between the production of research evidence and the timing of actual policy reform implementation.

DISCUSSION: Much of the focus of policy attention is on how to improve coordination within and across sectors, tackle socioeconomic inequalities and thus reduce the gap between perceived and observed need while monitoring any trends suggesting trans-institutionalisation. Other issues include developing and strengthening services to meet the needs of new migrants, as well as those of the rural population. There is also a growing recognition of the need to strengthen the evidence base both through research capacity and mechanisms to encourage the use of health economic information as one key component in the assessment of the system.

IMPLICATIONS FOR HEALTH POLICIES: The evolution of MHC in Spain may be regarded as a useful contextual case study for other countries embarking on reform, including some in Eastern Europe and Latin America. Spain is an example of a country that has undergone substantial economic and democratic transition in a short time frame; it has seen significant economic growth in some areas and has experienced mass immigration. While it is too early to judge the effectiveness of reforms in Spain, work to date clearly indicates some of the challenges that have to be overcome. These include better harmonisation and integration between health and social care, and more attention paid to the development or monitoring mechanisms to assess progress in reform implementation and better identify any widening of geographical disparities.