Gasto Público Sanitario Y Desarrollo Socioeconómico En Las Comunidades Autónomas Españolas: Evolución De Las Disparidades En Las Últimas Décadas

Resumen: El objetivo general de este trabajo es el estudio del nivel de desarrollo socioeconómico de una economía como factor explicativo del gasto público sanitario. Para ello, se descompondrá este objetivo general en tres objetivos específicos: en primer lugar, se tratará de estudiar la posición española a nivel de gasto sanitario en el conjunto de los países de la Unión Económica Monetaria; en segundo lugar, se analizará la relación existente entre el gasto público sanitario per cápita y el PIB per cápita; y en tercer lugar, se estudiará el nivel de convergencia experimentado por el gasto público sanitario a nivel de comunidades autónomas en la economía española. Tras el análisis de la evolución del gasto público sanitario por habitante y su vinculación con el nivel de desarrollo socioeconómico de las regiones españolas, a partir de la aplicación de un modelo de regresión y algunas técnicas estadísticas como son la convergencia sigma, el índice de Theil y el índice de desigualdad, se comprueba que los niveles de gasto público sanitario per cápita y desarrollo socioeconómico están estrechamente relacionados en estas regiones. En tal caso, se sugiere mantener el crecimiento económico que permita contraer las disparidades económicas de las regiones españolas, con la finalidad de reducir las diferencias actuales en el gasto público sanitario por habitantes. Abstract: The general objective of this work is to study the level of socio-economic development of an economy as an explanatory factor for public health expenditure. To do so, this general objective will be broken down into three specific ones: firstly, the Spanish position in terms of health expenditure in the countries of the Economic and Monetary Union as a whole will be studied; secondly, the relationship between public health expenditure per capita and GDP per capita will be analysed; and thirdly, the level of convergence experienced by public health expenditure at a regional level in the Spanish economy will be studied. This analysis allows us to observe whether territorial public spending has evolved in a similar way in all Spanish regions, placing the country's inhabitants in the same situation in this respect, or if, on the contrary, the evolution of health spending has been more unequal in the period analysed. This would show whether disparities in health expenditure are occurring between people living in the same country, according to the region in which they reside, establishing a pattern which allows us to distinguish whether health expenditure is and has been greater in regions with a higher socio-economic level or the opposite. In this way, it will be possible to define the level of socio-economic development (measured by the GDP per capita) as a determining factor of health expenditure per capita in all the Spanish regions in the period analysed (in principle 2000-2018), since it covers the last two decades and there is sufficient data to carry out a serious and rigorous study. The availability of databases on health expenditure implies that several statistical sources can be used. The aim of this research was to have a variety of statistical sources to enable a sufficiently long period of time to be covered for the study to be focused on structural issues, and not just on purely conjunctural aspects. This undoubtedly favours the achievement of more rigorous and timely reflections in studies of this type. The statistical sources used in this paper are as follows: Satellite Accounts on Public Health Expenditure (Ministry of Health, Consumption and Social Welfare of the Government of Spain); Satellite Accounts on Public Health Expenditure (Spanish Regional Accounts of the National Statistics Institute); Data on Health, Dependency and Pensions (Foundation for Applied Economic Studies); Public Health Expenditure (Valencian Institute of Economic Research); General State Budgets General Intervention of the State Administration (Ministry of Finance of the Government of Spain); and Health Accounts System (Ministry of Health, Consumption and Social Welfare of the Government of Spain); and Macroeconomic Data (Expansion Edition). With regard to the methodology used to address the proposed objectives, in addition to the description of the data presented, based on a territorial approach, the evolution of these variables and the possible relationship between them will be analysed, based on the correlation between them. Furthermore, an attempt has been made to establish the link between territorial economic development and the level of regional health expenditure by means of an econometric estimate. Similarly, another attempt will be made to measure the evolution of existing territorial disparities on the basis of indicators such as sigma convergence, beta convergence, the Theil index, and other indices that will make it possible to examine whether regional differences have been reduced or, on the contrary, intensified in the period analysed. An analysis of the evolution of public health expenditure per inhabitant and its link with the level of socio-economic development of the Spanish regions shows that the levels of public health expenditure per capita and socio-economic development are closely linked in these regions. The conclusions drawn from the study are presented below. Public health expenditure is an aspect that has a relevant influence on the whole population, so it guarantees equal opportunities and its distribution undoubtedly allows for social and territorial cohesion. In general, the public administrations of the countries with the highest level of income in the Economic and Monetary Union tend to make a greater effort to invest in public health, which may reflect the fact that health expenditure is closely linked to the level of economic development of the countries. Public health expenditure in Spain has accounted for around 70% of total public expenditure over the period analysed, and is, therefore, an element that can be used by territorial public administrations to try to stimulate the equalisation of opportunities for the population in each of the Autonomous Communities, as well as to promote the socio-economic cohesion of the Spanish regions. The distribution of public health expenditure among the Spanish geographical areas has been closely related to the territorial distribution of the population in the period analysed, but there are still strong regional differences in public health expenditure per inhabitant, which makes it somewhat difficult to achieve socio-economic equality among the Spanish Autonomous Communities. Furthermore, the growth of public health expenditure has been more positive than that of the Gross Domestic Product in the Spanish economy in the period studied, which has meant that public health expenditure per GDP has advanced positively not only at a national level, but also in all Spanish regions. However, it is necessary to point out that the intensity of growth at a regional level has not been equitable, but rather has been very uneven. It is also noted that the level of economic development is a determining factor in public health expenditure per capita. Logically, this has a fundamental impact on the process of territorial cohesion and equal opportunities that the Spanish economy is seeking. Regional disparities in public health expenditure per inhabitant have increased in the period 1995-2017 in the Spanish economy, as shown by the sigma convergence indicator, the Theil index and the applied inequality index. The breakdown of the Theil index shows how the increase in territorial differences in public health expenditure has been due to an increase of almost 30% in the regional investment effort in public health expenditure per GDP and almost 70% in the level of economic development of the Spanish regions. Moreover, according to the indicator of contribution to inequality, the regions with the highest share of inequality are Andalusia, the Basque Country and Madrid. The study shows that it would be desirable to reduce the range of dispersion between regions in the level of public health expenditure per inhabitant. Moreover, it is essential to identify the determinants of these interregional differences since they are a real obstacle to guarantee equal opportunities in the access to this type of services and to achieve higher levels of welfare in the population. Furthermore, it is crucial to establish a system that adequately protects the public health services provided by the territorial administrations in the face of the economic crisis and the fall in public revenue experienced in Spain over the last decade. Four key issues for the future are considered necessary: a) the sustainability of public health expenditure requires medium and long-term financial planning that is prudent and complemented by predictable funds provided in years of economic prosperity; b) the high territorial disparities in public health expenditure need to be carefully monitored and reviewed as they call into question equal opportunities policies; c) institutional loyalty must be adequately promoted so that territorial public administrations share the priority of these policies and can provide them with the corresponding funds; in this sense, a serious and rigorous debate on the level of sustainable public health expenditure must be addressed as soon as possible, taking into account the restrictions established by the high public deficit and the high public debt of the Spanish economy; and d) the regional financing systems must be adapted to the constitutional commitments to inter-territorial equity. In any case, it is suggested to maintain the economic growth that allows contracting the economic disparities of the Spanish regions, in order to reduce the current differences in the public health expenditure per inhabitant.