Sanitary Processes Sanitary System Models•1

THEME 1. Analysis of the healthcare organization in Spain. Models of

sanitary systems. Resources. public health system.
Legislation. Safety and hygiene regulations in centers.
health institutions.

Scheme:

1. INTRODUCTION
2. TYPES OF SYSTEMS.
2.1. Factors that determine a healthcare system.
2.1. Liberal.
2.2. Voluntary insurance.
2.3. Mandatory insurance.
2.4. National Health Service.
3. THE NATIONAL HEALTH SYSTEM IN SPAIN
3.1. Historical Evolution.
3.2. Principles.
3.3. Administrative organization.
3.4. Benefits.
3.5. Financing.
3.6. Gasto sanitario.
3.7. Deficiencies of the system.
3.8. Crisis of national health systems.
3.9. Reform measures.
4. LEGISLATIVE BASES
4.1. Spanish Constitution.
4.2. General Health Law.
4.3. New models. Legal framework.
5. SAFETY AND HEALTH REGULATIONS IN CENTERS
HEALTH INSTITUTIONS
5.1. Safety and hygiene.
5.2. Prevention services.
5.3. Applicable regulations.
6. Bibliography

1. INTRODUCTION
The components of human activity that are very diverse have
relationship with the health level of individuals and the community. This
has led to different definitions of health that, in turn,
they condition the existing health systems.
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Health processes Healthcare System Models•2

This makes health a relative and multidimensional concept:

dependent variable influenced by different related aspects
with the environment, lifestyle habits, biological factors, (food, housing,
water, climate, sport...). The World Health Organization (WHO)
consider that a health system includes components
interrelated with the environment, with educational institutions,
aspects of housing, working conditions and other sectors
related, which is why it recommends intersectoral collaboration.

The definition of health by the WHO, 'A state of complete well-being

Physical, mental and social" implies some prerequisites: "Peace, the
social justice, water and food, education and housing
worthy, as well as a useful social role and economic capacity
reasonable for everyone.” Health, therefore, is a variable
dependent on human biology, the environment, and lifestyles
life and the healthcare system.

As new conceptions have been accepted

Regarding the health-illness process, it is becoming increasingly important the
study of the corresponding health organization that responds to the
needs of the population according to these new concepts.

According to the WHO, health systems are understood to encompass all activities,
official or not, who provide health services to the population and
which also facilitate the population's access to these services of
health.

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A healthcare system is a set of devices responsible for the

healthcare services production, which are those that contribute to the
protection or improvement of health: on one hand, promotion and prevention and
of another, diagnosis and treatment.
The Spanish healthcare system, which is also called the National System of
Health has changed a lot in recent years, due to the
promulgation of two major laws by which it is regulated:
Spanish Constitution of 1978 and General Health Law of 1986.
The Spanish Constitution (art. 43) recognizes the right to protection
of health and it is the responsibility of public authorities to organize and supervise health
public through preventive measures and health services.
The General Health Law of 1986 completed the regulatory development
establishing that public healthcare will be extended to everyone
Spanish population.
Starting in 1989, the universalization of assistance was implemented.
sanitary. Its implementation led to an increase of one million people
that until then they did not enjoy healthcare from the
Social Security and a 4 percent increase in beneficiaries.
The healthcare system refers to the set of institutions, personnel
specialized, standards and means that provide health care to
a population. This health care includes:
Prevention: Avoid the onset of diseases (examples: vaccines,
campaigns against tobacco, campaigns to prevent the emergence of
skin and breast cancers...
Curing: Once a disease has developed (hepatitis,
flu, heart attacks, depressions...), use all available means
so that it disappears or heals and thus restore the
health.
One of the most prominent components of a national system of
health is its organization, for which various resources are mobilized,
with greater or lesser degree of centralization, depending on the distribution
geographical that is carried out.

The healthcare system must manage physical and economic resources.

humans. Management involves:

Planning: development of programs and creation of resources.

Administration: mobilization and effectiveness of resources.
Regulation: achieving quality standards.
Legislation: health policy.
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Health Processes Health System Models4

The exercise of a professional activity involves exposure to a

series of specific risks associated with the profession. The diseases
professionals are those suffered by the continued action of time
diversos agentes nocivos presentes en el medio laboral.

The problems related to the health of workers and users

The healthcare centers are as complex as the healthcare system itself.
structure of them, especially large hospitals, with
various subsidiary production processes (cleaning, maintenance,
hospitality,...) or related to the hospital's own function (exhibition
ionizing radiation, handling of toxic chemical reagents, risk
of infection, etc.). For this reason, health institutions must
ensure the safety and hygiene of their
workers.

2. TYPES OF SYSTEMS.

The five components on which systems are based

sanitary facilities are:

•Basic concept of health protection, with two positions of

basis, the egalitarian and the liberal.
Financing. Through taxes, social contributions, or direct payment.
Provision. Public or private, with a portfolio of services that
guarantee to a greater or lesser extent a continuous assistance and a
freedom of choice.
Population coverage of protection. Universal or individual.
• Organization of the system.

2.1. Factors that determine a health system

En la plasmación concreta de un modelo u otro de sistema sanitario

various factors influence:
The evolution of biosanitary sciences. The health advancements in
the discovery of the etiology, evolution, and treatment of the
diseases have led to multicausal theories and to the
delimitation of new health problems. This has caused
essential changes in healthcare systems to adapt to
the new needs.
Healthcare spending. Healthcare spending has evolved and is evolving.
exponentially, not following the same evolution, the
health benefits that are obtained from it.
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Sanitary Processes Models of Health Systems5

Other factors that contribute to the configuration of a certain

type of health system is the social and political system in which one goes
to develop the health system and the configuration of the different
professional groups.

The decision about the best healthcare model would be based on the
cost-effectiveness. Although the cost can be established relatively
ease, the measurement of the effectiveness of a healthcare system is a matter
quite complicated, among other reasons, due to the difficulties of
health measurement.

The differentiating factors of the four major health models

theoretical are: financing, management, regulation and use.

Financing. The form of financing defines the characteristics of the

protección de la población frente a los riesgos sanitarios, El
insurance implies the availability of funds to cover expenses
what will be incurred in old age, a period in which the weight of the
diseases is greater. The redistribution of funds has a
social component, as it implies the willingness on the part of
those who have the most to meet the needs of the least
beneficiaries. The financing can be of two types, public or
private.
Private financing it can be paid in two ways
different, a) direct payment or by act, where there is no production
no rent guarantee function; or, b) indirect payment, where
It is paid through installments for an insurance whose price will depend on the
risk they have at every moment.
Public funding is basically that which is nourished by the
state taxes, although it can also be through a
mandatory insurance, in which case it is considered a type of financing
mixed since the taxpayer (workers and entrepreneurs) pay a
amount (Social Security).
•Management. Healthcare organizations operate between two
extremes. On one hand, those that are part of the non-differentiated
healthcare system and on the other hand, the independent ones, privately owned,
that depend on the sale of their services in the market to
achieve their goals.

La primeras son instituciones que ofrecen todos sus productos a

change of a budget, here the decisions usually fall
in different organisms (Parliaments, Treasury, Health,...) and are
determined by very diverse criteria (macroeconomic indices,
laws, health objectives,...
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SANITARYPROCESSES Models of Health Systems•6

They are not profit-oriented and the executives have very little margin.
of maneuver since the management functions are largely
predetermined. In an organization of this type, at least one
part of the periodic income comes from grants or
government budget allocations. The improvement or the
deterioration of the results do not have a direct impact on
the personal situation of the individual deciding or of the organization.

Independent organizations with private ownership achieve

its financing through service units at prices of
market. Here the competition with other organizations is based on
the volume, the price, and the perceived quality of its services. The
The more services a manager sells, the more resources he obtains. The
Incentives for the executive to choose the best alternatives include
in this case, not only their satisfaction and prestige, but also the
increase in resources available for your organization.
•Regulation. These are the norms that regulate how things should be done.
those services. Depending on the management, they can be very lax
(private) or very strict, becoming laws (public).

•Usage. It refers to the type of user who has access to these.

services. The use of services is determined by factors
epidemiological, sociodemographic, and organizational.

The epidemiological factors refer to the use of

part of the population of health services. The professional
healthcare professional who decides what and how many services the patient should use
largely determines the use of services. Although
also, the perception of the need for care determined by the
cultural, social environment and the psychological characteristics of the client is
an essential factor for the use or non-use of the services.

Sociodemographic and cultural factors include factors

related to the population and the consideration of disease by
part of society. The user or client decides to use the services
depending on how the illness feels, the advantages of the
attention and the disadvantages of it.

The availability of resources and geographical accessibility

Socioeconomic factors also influence the utilization of services.
sanitary facilities. The availability of resources is the relationship between the
quantity and type of services provided and health needs
of the population.

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Geographical accessibility is the relationship between the location of the

provision of the service and the location of the potential user or the
health needs, expressed in distance, time or cost of
transport. Socioeconomic accessibility is defined by the
acceptance of the services available for an individual or a group
social determinado y por la existencia o no de barreras económicas
for its use.

Taking into account these four criteria, health systems

they classify into: liberal, voluntary insurance, mandatory insurance and service
national health.

2.2. Liberal.

The funding is private and the payment is direct. Its use is

influenced by the economic factor and the perceived need. The power
the customer's purchasing power is what determines its use, making it
health prevention is almost nonexistent. Coverage will be very
unequal, as there will be more and better healthcare services where there are
more demand, as in large cities.

The entity that regulates is usually the one who provides the service (doctors,
nurse, physiotherapist), although professional associations set
some minimums, but very lax.

Management mechanisms are those that regulate the private economy.

(they hire and buy more easily than the public), although they have
regulatory standards. In short, they are more agile in management.

The liberal model adapts to the market. They are continuously

observing what the population demands. They themselves regulate the management
and offer services according to demand and the benefits they can provide
take from her. The liberal system is chronologically the most
ancient.

2.3. Voluntary insurance.

It arises as a consequence of liberalism, being its philosophy, therefore, very

similar, but it has the advantage that the person can have a
safer coverage.

The financing system is the premium that covers risks and services.
that the client chooses, but generally the more expensive ones are not given by the
insurers for reasons of profitability.
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SANITARY PROCESSES Models of Sanitary Systems•8

The use is by the person who can arrange that policy according to
its economic situation. The regulation is that of the company itself
the insurer demands, deciding which services it provides and which it does not. The
management is also established according to the demands.

Typically, the insured can freely choose a provider and it is

it's common to have to pay a small amount each time I use it
a service (moderator ticket). Companies compete among themselves to
increase your affiliates.

2.4. Mandatory insurance.

The Bismarck system, which was inspired by social legislation of

Germany in 1883, is the social security system. It has the
following characteristics:

Mandatory universal coverage within the Security system

Social.
Financing through contributions from employers and employees,
through a non-profit insurance fund, not
governmental.
Public and private ownership of the means of production.
Public and private provision of health care.

Austria, Belgium, France, Germany, and the have adopted this system
Netherlands.

It is the first attempt at public assistance without actually being so, as it is conceived.
currently. It was created after World War II emerging from a
new philosophy, that of the welfare state, where the state becomes
charge for services that the private source does not provide and that can
to lead to conflict (this idea originated from Bismarck).

The mandatory insurance arises from the old workers' resistance funds.
It is not a public system, but it is a system regulated by the State.
where the financing comes from the employee and the employer. The
use is initially marked by the workers and in
the function of different situations expanded, reaching
access to the system for the holders (workers) and the beneficiaries (family).

In these first three (liberal, voluntary insurance, and mandatory insurance),

The economic aspect determines its use. Coverage is not universal.
the type of services is restorative medicine and accessibility
it depends on the market conditions.
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HEALTH PROCESSES Models of Sanitary Systems9

2.4. National Health Service.

It is inspired by the Beveridge Report of 1942, which formalized the

organization adopted by Sweden in the 1930s. This modality
it began to take shape in the 1940s due to the
social conflict and democratization and social participation in
these types of problems. It ultimately establishes a National System
of Health. Its characteristics are as follows:

Universal coverage: free access for all citizens.

Funded by taxes, through state budgets.
Managed and controlled by the Government.
State ownership of the means of production, although there is a
part that is privately owned.
Public provision, mostly, of health care.
Doctors are salaried.
There is a contribution to the payment from the patients.

The countries that have adopted this system are: Denmark, Finland,
Ireland, Norway, Sweden and the United Kingdom, which adopted it after the
World War II; and Greece, Italy, Portugal, and Spain have it since the
1980s.

Funding is basically public and through taxes, although

lately this maxim is changing, and in some countries they are
incorporating a fee based on the number of times one attends the
health services.

This system is regulated by the Government, usually with a framework law that
it is modified through subsequent laws and decrees (Spain,
General Health Law 1986.

The management is the same as that of mandatory insurance, a type of management.

which hinders the agility of the system.

The use is universal. In theory, every citizen has coverage,

but this action is contingent upon the availability of the service and
the accessibility of the population.

The services offered are broader and not only are

dedicated to curative medicine, but also to preventive medicine and to
care for chronic patients.

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SANITARYPROCESSES Healthcare System Models10

In summary, the common characteristics of all Systems

Health Nationals are: a) tax funding: effects
redistributive, b) universal coverage: right to care, c)
assurance: public, d) regulation and allocation of resources:
administrativa, e) prestaciones sistema: comunes, f) elección usuario:
relative and g) Provision: mostly public.

2.6. Resumen

In most countries, there is not a single healthcare system, the

four survive with greater or lesser strength. These archetypes do not
they are applied strictly, even if the characteristics of one prevail
they also collect something from others.

Depending on the type of provision (who provides the healthcare services)

and from the financing (who pays for those services) arise the systems
sanitary facilities provided to countries. The following table illustrates this:

PROVISION
PUBLIC PRIVATE
FINANCING

Social security; mutuals

labor (health, old age);
SYSTEMS mandatory insurance
NATIONAL HEALTH disease. To
PÚBLICA (UNITED KINGDOM, to increase the
SPAIN, COUNTRIES solidarity, the state
transfer funds (Germany,
NORDICS France

Pure liberal system (USA)

but with programs
THERE DOES NOT EXIST ANY
PRIVATE specials: medicare
SYSTEM (elderly) and Medicaid
(poor)

3. THE NATIONAL HEALTH SYSTEM IN SPAIN

The National Health System is configured as the set of the

health services of the Central Administration and the Communities
Autonomous. Health care is extended to the entire population with
public funding and provision, also basically public,
supplemented by the private concerted.

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The General Health Law, of April 25, 1986, establishes the System
National Health through a gradual process, integrating the various
existing public sanitation subsystems (social security,
charity, etc.).
Despite this, there are some exceptions. The officials of the
State Administration, Local Entities, Justice, and Forces
Armed forces have a separate protection regime through
state mutual societies, which can arrange health care with
entities of private insurance or with Social Security. Likewise,
certain number of important companies that meet specific
conditions, they have become "collaborating entities" and provide
a personalized assistance to its beneficiaries, which total around
of 700,000 people.
Finally, a part of the population (around 5,500,000 people)
he has chosen to subscribe to a health assistance policy with a
private insurance company, even though a large part of it is quoted
in addition to Social Security.
Therefore, several systems coexist in Spain:
1. National Health System. It is the hegemonic one. It provides coverage.
to practically all citizens. Fundamental characteristics:
• Universal coverage.
Health coverage
Source: Eco-Health 2003, OECD
100
90
80
70
60
50
40
30
1960 1970 1980 1986 1990 1992 1994 2000

Funding through taxes.

Public healthcare funding (Millions of euros)
Source: Eco-Health 2003, OECD

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Decentralized.
Total health expenditure. SNS budget per capita. 2004.
Economic resources of the SNS. Data and figures. MSC.

Mostly public provision.

2. Mutualities: Muface, Mugeju, Isfas.

4% coverage of the population.
Public systems.
Corporate systems funded by contributions from
workers and the Administration.
Contracts for services with public and/or private entities.

3. Collaborating Companies of Social Security:

Public system.
1% coverage of the population.
They take on the organization and management of one or more of the
social security benefits (common illness and
work-related accident.

4. Private insurers:
Benefits according to the signed policy.
Private contracts.
Provision with own or subcontracted means.

5. Centers and self-employed professionals:

Individual acts.
Concerts.

The General Health Law establishes the following general principles:

Priority to health promotion and prevention of the
diseases.
Its extension to the entire Spanish population progressively.
Access under conditions of effective equality.
Overcoming territorial and social inequalities.
Community participation through territorial corporations.
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The competencies of planning and health management correspond to

to the Autonomous Communities ([Link].), without prejudice to the
general health coordination, which is a state responsibility. The Council
Interterritorial Health, composed of representatives from the Autonomous Communities.
of the State, presents enormous importance as a permanent body
of communication and information of the different Health Services between
them and with the state administration.

3.1. HISTORICAL EVOLUTION

To understand what the Spanish healthcare system is like today,

It is necessary to know its origin and evolution.
Until the 20th century, the State was responsible for collective health. The
individual health problems had to be resolved by themselves
citizens turning to private medicine. Charity and the
religious or guild organizations (mining, construction...) are
they were concerned with those who could not afford medical assistance.
Starting in 1900, assistance insurance began to be created for
specific sectors. The first was occupational accidents, and
after the one of illness, maternity...
In 1919, the National Institute of Social Welfare (INP) was created.
turn into the general manager of all these insurances that had gone
appearing in a disorganized manner.
In 1942, the law for mandatory health insurance is approved.
(SOE). It was a national health insurance service for
workers, their families, and pensioners. At the same time, there was a
private assistance (paid) and another type of charitable assistance.
In 1974, the general social security law established a
more modern healthcare system, featuring elements such as the
free choice of general practitioner, pediatrician, and gynecologist, contribution
of the insured in the expense for medications, greater investments
in hospitals and technology...
After the first democratic elections (1977), the
Ministry of Health and Social Security, which includes many
services and resources that had been scattered across several
institutions. In the following years, the scope has been changing
competencies of this ministry, its internal organization and even its
name, which is currently the Ministry of Health and Consumer Affairs.
•En 1978 desaparece el Instituto Nacional de Previsión ( INP ) y se
three new institutions are created that will share their responsibilities.
NATIONAL INSTITUTE OF HEALTH (INSALUD): Is responsible for
manage and administer the healthcare services of Social Security.
Currently, it only manages those communities that do not have

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transferred the health competencies. It is under the

address of the Ministry of Health and Consumption.
NATIONAL SOCIAL SECURITY INSTITUTE (INSS): It
is responsible for managing the economic benefits of the
Social Security.
NATIONAL INSTITUTE OF SOCIAL SERVICES (INSERSO):
Responsible for directing complementary social services to
the previous ones and managing pensions (of disability and of
retirement) and also non-contributory pensions, which are those
that are granted to those over 65 years old who reside in
Spain, lack sufficient economic resources to subsist
and do not have the right to receive a contributory pension for not having
never quoted, or at least long enough, to Social Security
Today it is called IMSERSO (Institute of Migrations and Services
Social.
In 1984, the reorganization of the levels of assistance begins.
Up to this moment, at the first level of assistance were the
ambulatory clinics, in the second the specialty ambulatory clinics and in
the third hospitals. The sick were referred successively
from one level to another. With the reorganization of 1984, the
primary care teams, which replace outpatient clinics,
constituting the first level. At a second level remain the
Specialty Centers and Hospitals.
In 1986, the General Health Law was approved, and the System was created.
National Health. Currently, healthcare in Spain is regulated
through the Constitution and through this general law.
• In the 90s, new formulas have emerged such as the
prospective budgets, the units of measurement, the contracts of
management, the legal personification proper in new centers
(hospital foundation, public hospital company), the preparation of
corporate strategic plans or the enhancement of units
clinical management, in response to the crisis of the National Systems of
Health.

3.2. Principles.

The essential principles that the Spanish healthcare system assumes are
the following:
Universality: Total coverage of the population.
Integrated care: Promotion, prevention, treatment and
rehabilitation.
Resources: Distribution of them according to needs
health of population groups.

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Efficiency: Achieving the best possible level of health with the minimum
cost
Participation: In the planning and management of the healthcare system
citizens participate.

In Spain, the national health system is financed through taxes.

that is to say, with public funds.

3.3. Administrative Organization

There are three administrative levels that configure public health:

Central level.
Autonomous level.
Health area level.

The central level is represented by the Ministry of Health and

Consumption (MSC), which retains the ability to propose and execute.
the government's general guidelines on health policy and maintains
the general coordination of health, which has been transferred to the
different Autonomous Communities. The competencies of the MSC, according to
the General Health Law is:

External health and international relations.

High inspection.
Accreditation of centers and training.
Epidemiological surveillance.
Regulations on: environment, food and
medications

To ensure this overall coordination between the Administration of

The State and the Autonomous Communities created the Interterritorial Council.
of the National Health System, an organ for information,
communication and coordination between the different Health Services of
each Autonomous Community and with the State Administration. This
the council is made up of representatives from the Communities
Autonomous and by members of the State Administration, which
They meet under the presidency of the Minister of Health and Consumer Affairs.

Autonomous Level. Each Autonomous Community constitutes a Service of

Health, made up of all the centers, services, and establishments of the
own autonomous community and is organized through the Department of
Health.

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Each Community can develop a Health Plan, which must

adjust to the guidelines set by the General Health Law and
to the general coordination criteria approved by the Government
Central. The Health Service of the Community divides this into several
Health Areas.

For example, the Health Department of the Community of Madrid has

a deputy ministry of health assistance and infrastructure, one of
whose general addresses are the General Directorate of Health Network
public use only, on which the Madrid Service depends
Health.

Health Area Level: The Health Area is the geographical unit and
functional of the health system. Each Area works in a different way
autonomous, studies the health needs of the population that
covers, adjusts its resources to meet these needs ( Plan
of Area Health) and coordinates and manages the services and establishments
existing in your area.

There must be at least one Area per province. Each area serves
populations of 200,000 to 250,000 inhabitants. In Madrid, for example,
there are 11 Health Areas, each with its own management of
Specialized Care and a Primary Care Management.

The primary care management divides its Health Area into Zones
Health Basics, where primary health care is provided,
is carried out by Health Centers or Care Centers
Primary formed by a Primary Care Team and units of
support.

In each Area, there are two levels of care:

Primary health care: Includes health promotion,

disease prevention, treatment and rehabilitation. It is carried out
in health centers, by teams in which different people work
professionals, who are called care teams
primary.
• Specialized care: It is provided at specialty centers and
in hospitals. In each health area there must be at least one
hospital. In the hospital, patients are attended to in a regime of
internment. Provides specialized diagnosis and treatment
when the possibilities of the Health Center have been exhausted
overwhelmed. Emergency cases are also attended to.
vital.
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3.4. Benefits

The content and scope of social assistance benefits are common.

for the entire system. The current regulations govern the organization of
healthcare benefits of the National Health System.

Establish the non-financed benefits charged to security.

social or state funds allocated for healthcare assistance. In their
generic definition, the benefits are:

General medicine assistance and all specialties

ordinary and emergency medical services.
•The treatment and stay in health centers and establishments,
including free pharmaceutical treatment and prosthetics.
The outpatient pharmaceutical provision, excluding
dietary products, cosmetics and analogues (a provision is established
patient's participation in the cost of the service, which in the
the actual percentage is 40% of the selling price, only for
active workers.
Other healthcare benefits, such as prosthetics, vehicles for
invalids and home oxygen therapy.
The transportation of the sick.

Rehabilitation.
The LGS emphasizes health actions aimed at promotion
health, health education, disease prevention and the
rehabilitation and reintegration of the patient.

The most important limitations regarding performance are those that

they refer to dental assistance (only extractions are accepted)
simple), to the slow process of integrating psychiatric assistance and to
the very limited promotion of health and health prevention that is
effect

The evolution of healthcare services of the National Service of

Health over time is reflected in the following parameters:

Decrease in the number of hospital beds (39 per 1000)

inhabitants) and the average stay, 9 days. Data from the year 2000.

Increase in hospital discharges (120/1000 inhabitants), of the

emergencies attended (500/1000), of the surgical procedures (92/1000) and
from outpatient major surgery (17%). Data from the year 2000.
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3.5. Financing

The financing system changes substantially starting from the year

1988. Up to this date, there is a majority contribution from the
Social Security, through the contributions of employers and
workers through contributions on wages. As of this date the
the majority contribution comes from the General Budgets of
State.
Public health financing. Millions of euros.
Source: Eco-health 2003 OECD.

Public provision resources are insufficient for care of

the entire population benefiting from health assistance. It is necessary
establish agreements with those private entities that
complement the existing public offer. The distribution of beds of
the whole system indicates that 30% of the beds are owned
private.

This proportion is not the same in all Autonomous Communities.

The average size of public hospitals is much larger than that of the
private hospitals. This translates to the fact that the latter, unless
exceptions, carry out simple medical and surgical treatments,
leaving the more complex pathologies for public hospitals.

3.6. Health expenditure

Various factors contribute to the increase in healthcare spending everywhere.

developed countries and in particular:

The aging of the population. The increase in people

Higher taxes not only have the effect of reducing tax revenues.
or the contributions, but an increase in healthcare spending, since
that have greater objective needs.
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SANITARYPROCESSES Healthcare System Models19

•Technological innovation. The new technology in the field of

electromedicine has generated a notable increase in spending, even
when its use is not always effective, nor even necessary in
some cases.
New pathologies and chronic diseases. Certain
unhealthy lifestyles and habits are the cause of the emergence
of new diseases, with a significant increase in spending. The
modern medicine, capable of supporting chronic patients,
It also leads to a significant increase in healthcare consumption.
Change in the level of demand from patients. It is evident that the
increase in the standard of living and the education of individuals, linked to
a greater awareness of participation in social expenses to
through taxes, they have led to a greater demand in the
quality of services.
Evolution of healthcare expenditure as a percentage of GDP

Source: OECD Health 2003

6

4
public
3
private
2

0
1960 1970 1980 1990 2000

All these factors influence the possibility of a significant increase in

healthcare spending in the coming years, very much in line with the
evolution that the countries in our closest environment have undergone. In
In Spain, healthcare spending, according to data from the MSC in 2004, amounts to
1088 euros per capita; which represents 7.8% of GDP.

3.7. Deficiencies of the system

A large majority agrees on the need for a reform of

actual system, due to its difficulties in achieving recognition and
satisfaction for an increasing part of the population. The
The most notable deficiencies can be summarized as:
Primary care, which should be the entry point of the system
assistance, does not fulfill the exact role assigned to it and is
cause of imbalances that overload the activity of the
hospitals.

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HEALTH PROCESSES Models of Health Systems20

Specialized assistance absorbs a percentage of public spending.

which continues to increase.
The public system does not allow patients the freedom of choice.
There are only evaluation and analysis mechanisms for attendance.
sanitary.
The statutory labor framework does not allow for their establishment.
criteria of efficiency and productivity in healthcare assistance.
The management of health officials clashes with a system
rigid and highly centralized regulation.
It seems clear that modern healthcare services require a
adaptation of management instruments to new needs,
abandoning obsolete structures that lead to situations of
inefficiency and dissatisfaction.

3.8. The crisis of public health systems.

Universal access public health systems assume with

limited resources the provision of services without natural limits.

But this limit of resources in healthcare takes on a

peculiar gravity: needs are indefinitely expandable and
categorical for society, the needs in health care do not
They have an end; but the economic resources to cover them do not.

In recent years, a set of factors has accentuated this

original instability of National Health Systems: the
propagación de la economía liberal, la idea de que “el consumidor es el
that pays,” the increase in income level and living standards and the
the expiration of the administrative criteria of public assistance is
examples of this. Let ’s take a closer look at some of these
factors:

Administrative rigidity.
The management of health officials clashes with a system
rigid and highly centralized normative.

The need for progress and adaptation to health problems is seen

hindered because in order to make a change in health matters
it must first pass the approval of an administration that establishes some
inflexible administrative guidelines: proposals, budgets, requirements
and signatures,... that slows down the necessary transformations in order to be able to provide
a better service.

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2. Inefficiency.
Efficiency in public systems is hindered by:
Public law stifled management: it is very difficult
change what can be improved.
Disconnection between clinical demands and their consequences
economic matters: the healthcare professional does not participate in management of
the resources.
The lack of knowledge about the costs of services: it is not known or
one is not aware of the cost of a service and, therefore,
there is excessive and unnecessary spending.

3. Perverse incentives.
Public systems have guaranteed positions for workers
they cause a lack of stimulation, making professionals be
few prone to change and that recycle themselves scarcely over time
of time.

On the other hand, the systems penalize sensible management, for example a
hospital that would have improved the quality and efficiency of a
determined service and achieved a reduction in its list of
I would probably expect to receive more patients, but not more resources.
to face them.

Also, if a hospital fulfilled its functions with surpluses, per year

the following amount saved would be reduced in the budget for
to have a zero balance.

4. Disinformation.
There is no information about what is done and what each thing costs, it is
say, there is a lack of economic and clinical information about what is done. The
the poverty of information prevents linking the resources used with
the results achieved.

User dissatisfaction.
The features of the system seem designed to meet the
needs of professionals instead of the sick, moreover, there is
a lack of quality controls and personal relationship with the
patient.

6. Politicization.
Excessive centralization and bureaucratic passivity lead to blame.
from the system's errors to the government, causing it to delay
essential or paramount actions due to fear of the consequences.

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7. Technology.
Technology is advancing by leaps and bounds, but not all of it has been
investigated or analyzed enough to know if it is effective and
better than the current one. For this reason, there are already agencies that assess the
relationship between cost-effectiveness of emerging technology.

8. Aging of the population.

Every day, the number of elderly and vulnerable people multiplies.
growing assistance needs. This involves costly changes.
in the way of assistance and in the facilities.

9. Increase in income level.

Practically in all industrialized countries, the relationship between the
percentage changes in healthcare spending and Gross Domestic Product
(GDP) is greater than 1, meaning that increases in GDP cause
largest increases in healthcare spending.

10. Epidemiological changes.

The increase of chronic patients, the emergence of new diseases
and the increase in mental illnesses creates a problem
social, and at the same time, the State does not fully cover or in some aspect the
disease due to the high healthcare costs they entail.

It is also influenced by the fact that more and more people are asking to be
assist in health situations and not only when there is an illness.

11. Quality care.

Few people doubt the scientific and technical quality of the professional. The
aspects that are lacking are related to the treatment and the
service offer.

Complaints and claims arise from the dehumanization of the

sanitary services and that the professional-client relationship leaves a lot to be desired
what to wish.

The environment where services are provided also influences the appreciation of
the quality, for example, chipped walls or rooms without a bathroom
with six beds and no privacy at all makes the user not
find comfortable.

In the face of these problems, public services have set objectives to

quality in service delivery, although it is not easy to establish
quality indicators. Still, quality controls will be part of
of the main obligations of public health.
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SANITARY PROCESSES Models of Sanitary Systems23

12. Risky lifestyles.

Unemployment, working in poor conditions, an unbalanced diet, the
sedentary lifestyle, tobacco, alcohol, sexual promiscuity, speed
in the automobile, etc., are pathogenic agents that today's society
fosters.

13. Respond to the demand and not just to the need.

The national public systems of universal free access establish the
need as the sole principle of resource allocation, with which,
efectivamente, el enfermo está técnicamente bien atendido, pero sus
Personal desires are not taken into consideration.

In industrialized societies, the increase in income levels, with the

subsequent sociocultural development and the progressive exercise of the
freedom has transformed the passive consumer into an active one, more and more each day
disgust in the current assistance systems, which depersonalize
to the sick, they limit or annul the ability to choose, they restrict intimacy,
etc.

Therefore, the criteria and forms of public assistance are now seen
in the commitment to attend to and embrace the patient's wishes,
consider their tastes, offer complementary services, in short,
incorporate the concept of the client. They must respond to the demand without
forget justice in the assistance to need.

14. Role of the State.

Today's society acknowledges the achievements in health care.
public, but does not admit its heaviness of movements, nor its
insensitivity towards the consumer.

On the other hand, public sector monopolies have not achieved the
the effectiveness and efficiency needed, and distrust grows in the
state machinery for resource allocation.

[Link] measures.

The reform measures are basically based on these 4 reports:

•1986. Dekker Report, Changes Assured. Netherlands. Attempts to increase
the competition in the offering of services (suppliers) and that the
user can choose. Introduce the participation of the private sector in
competition along with the reduction of public participation in the
system.
•1987. Proposal by Saltman and Otter. Sweden. Follows the trend of
Holland, but does not include the participation of the private sector.
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SANITARY PROCESSES Healthcare System Models24

1989. Working for Patients. United Kingdom. Creates the internal market.
within the competition, each assistance act is given the
product category. This internal market competition implies
that the providers must have defined the services, where the
intermediary (who buys) is the primary care doctor. He has
awarded a group of patients according to the needs
It will control the services. Thus, it becomes the center of the market.
•1990. April Report. Spain. Introduces the concept of market
public system with public or private providers, but not
it opens to free choice. Also, while in the United Kingdom
who regulates is the doctor, here they centralize it more in the unit
manager within a territory (health area). The family doctor
Choose the tests to be done, but not where they should be done.
However, some changes are required for this:
Final homogenization of financing levels of the
different Autonomous Communities and establishment of criteria for
distribution of resources accepted by all.
Design of new service provision structures at the level
extrahospital
generalized transformation of public hospital centers in
authentic service companies.
Deregulation of the administrative apparatus or transformation of the
statutory character of healthcare personnel, generalizing the relationship
labor
Collaboration of the private sector.

As a result of the crisis, the National Health Services of

the conclusions of these reform reports and the attempts to
improvement, health systems try to ensure these five objectives:

Adequate and equitable accessibility. The aim is to fulfill the objective

maintaining or increasing the coverage of mandatory insurance and
increasing voluntary insurance.

In response to health needs, the population can access in a way

easy and agile to the requested service, such as not being longer than
6 months on the waiting list, having to go abroad so that we
provide an appropriate service or that it does not take longer than 30 minutes
upon arriving at the healthcare center. On the other hand, when we talk about equity
it must be taken into account:
Equal need, equal treatment.
Equal access for all.
Health equality.

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SANITARY PROCESSES Models of Health Systems25

2. Guarantee of income level. Falling ill means a disruption.

in the family economy, therefore public systems try to
satisfy this problem regarding:
•Insurance. When suffering from an illness, the expenses do not
at the expense of the family economy.
Savings. Ensure a level of income for the elderly, since
they face two problems: retirement, which decreases the level
of rent, and the increase in age, which entails an increase in
healthcare consumption.
Redistribution. Of money, so that the lower classes and
disadvantaged people receive more help

3. Macro and microeconomic efficiency. Efficiency means achieving the

better results with the economic resources available
disposition.
Macroeconomic efficiency. It means that the part of GDP spent
in health services is sufficient to achieve the levels of
well-being consistent with the level of development of the country, but that to
at the same time does not consume more resources that could be more
beneficial used in other sectors, such as education or
defense. It is aimed at regulating spending at the global level and the
the measures are basically of a political nature:
Prospective budgets. Avoid retrospective payment. In the
contracts quantify the activities of the centers and what is going
to pay for them.
Payment by process. Define uniformly which processes will be
do. Each center must define the standardized processes it will
to be done and how much it will cost.
Planning/ Approval of new services. In a territorial manner,
They are planning the new services that the system will offer.
Evaluation of new technologies. Through technical committees.
The efficiency of new technologies coming to market will be evaluated.
before integrating into the system.
•Microeconomic efficiency or productivity. It aims to optimize the
resources invested in health services. The aim is to achieve
greater results with the same resources or, by decreasing them,
maintain the level of results. The measures to ensure the
microeconomic efficiency is aimed at improving the
productivity; that is to say, doing more with the same amount:
Separation of funding from service provision. This incentivizes
productivity.

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Competition. Introducing various types of suppliers

A competition is being established automatically, throughout
controlled case.
Multihospital system. It is possible to refer to another, cheaper hospital.
and complements the action of the other, or ensures assistance in
address.
New diagnostic and therapeutic techniques that are cheaper.
Incorporation of new management techniques. They are being introduced.
techniques used in the private company: strategic planning or
management by objectives. Services are being designed
diversifying the products.

4. Improvements in health levels: There is no relationship between some

mejores indicadores de atención médica y una disminución de la
mortality. The variables that are best related to good
health indicators are per capita income and low levels of
tobacco use and consumption of alcohol and sugar. The characteristics
organizational factors also influence and a study relates the greater
improvement of certain attention characteristics
primary school with the best results in satisfaction levels in
relationship with spending and certain health indicators.

In a specific period of time, objectives are set for

health periodically based on health plans that
they analyze in detail the health level of the population.
From here, an action is created.

5. Customer satisfaction: It is very subjective and hard to define indicators.

let them instrumentalize it. Satisfaction depends on the experience and the
situation of each client; however, measures tend to be introduced to
satisfaction as customer-oriented service marketing or the
satisfaction surveys.

In countries with universal coverage and public funding, the levels

satisfaction is better in those where there is private provision of
services and greater choice capacity. There also seems to be a
correlation between higher healthcare spending per capita and greater satisfaction
(except for the U.S. and Sweden).

In any case, elements such as the lack of healthcare coverage for

an important part of the population, the uncertainty regarding the future
or the necessity to contribute directly with a part of the cost for the
patients are factors that influence low levels of
satisfaction.
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HEALTH PROCESSES Models of Health Systems•27

4. LEGISLATIVE BASES:

As stated, the National Health System is based on the

Constitution and in the LGS. Subsequently, new ones have emerged.
laws and decrees, clarifying and expanding different aspects of
ordenamiento sanitario.

4.1. Spanish Constitution (1978)

It establishes:
The right of all citizens to health protection.
The obligation of public authorities to maintain a regime
public social security that guarantees assistance and the
social benefits to all citizens, even in case of
unemployment.
That the state is organized into autonomous communities, that
they will have independence to manage their own interests.
Consequently, the state has decentralized the system.
healthcare, transferring its organization and management to the
autonomous communities and maintaining only competences
global and coordination
The definition of the health model.
The general coordination of Health.
The health statistics of national interest.
The regulation on pharmaceutical products.
International health relations, in sectors such as control
epidemiological, environmental conservation, control of
international transit of goods and travelers...
the high inspection, which includes evaluation activities and
monitoring of the management of the autonomous communities.

4.2. The General Health Law (1986)

Define y estructura lo que será el sistema sanitario español,

responding to the new demands posed by the approval of
the Constitution
Extension of services to the entire population.
Comprehensive health care (health promotion, prevention of
diseases, healing, and rehabilitation.
Funding through public resources, contributions from workers
and entrepreneurs and rate of certain services.
Health promotion.
Disease prevention.

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SANITARY PROCESSES Health System Models28

Health education.
Health care.
Rehabilitation and social reintegration.

4.3. New models. Legal framework.

In order to provide the healthcare system with an opening of its own

organization (possibility of searching for new markets) and a greater
efficiency and flexibility, new laws and regulations emerge:

Law 15/90 on health regulation in Catalonia.

1992, prospective financing system and explicit contracts in
Specialized attention.
1993, exclusion of public funding from a selective list of
drugs.
In 1995, the Catalog of Benefits of the National System is established.
de Salud.
Decree 10/96 on New Forms of Management in the SNS.
Strategic plan of INSALUD, 1996. Establishes programs oriented
to the proper use of resources and to control spending
pharmaceutical at reasonable levels comparable to those of the countries of
our environment, introducing mechanisms of proven effectiveness, and
that generate short-term results.
Law 15/97 on New Management Forms in the SNS.
1999, possibility of hospitals as independent agencies:
Foundations.
Decree 29/2000 on New Management Forms in the SNS.
Specific laws for the creation of new legal forms in centers
sanitary (Foundations, Public Companies).

5. SAFETY AND HYGIENE REGULATIONS IN CENTERS

HEALTH INSTITUTIONS

The General Health Law, 14/1986, dedicates its Chapter IV to Health

Labor and in its Article 21 indicates the aspects that must be included
healthcare action in the field of Occupational Health, specifying them in
the following :
Promote, in general, the overall health of the worker
Act on the health aspects of risk prevention
professionals
Likewise, the working and environmental conditions will be monitored.
may be harmful or unhealthy during periods of
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SANITARY PROCESSES Models of Sanitary Systems29

pregnancy and lactation of the working woman, accommodating her

work activity, if necessary, to a compatible job during
the referred periods
Determine and prevent workplace microclimate factors regarding
can be causes of harmful effects on health for the
workers
Monitor the health of workers to detect early and
individualize the risk factors and deterioration that may affect
the health of them
Develop, together with the competent labor authorities, a map
of occupational risks to the health of workers. To these
effects, companies are obligated to communicate to the
relevant health authorities the substances used in the cycle
productive. Likewise, an information system is established.
health system that allows for epidemiological control and record of
morbidity and mortality due to occupational disease
Promote information, training, and participation of the
workers and employers regarding the plans, programs and
health actions in the field of Occupational Health

The LGS also indicates that one of the functions of hospitals is the
health promotion and disease prevention, with which the
hospitals must control, know, and assess the safety of
users and staff.

[Link] and hygiene

The concept of safety and hygiene involves the development of a series of

actions aimed at achieving the prevention of accidents,
diseases and damages, eliminating as much as possible the
risk factors, as well as protection against those risks that
they cannot be eliminated and it is necessary to assume, both by the staff
of the healthcare center as well as by its users. To achieve this, it is necessary
follow these three phases:

1. Identify the risks. The agents that most frequently cause

occupational diseases and workplace accidents in the healthcare sector
son
a) Physicists.
Construction safety of the workplace.
Ionizing radiation: X-rays, CT scans, radioactive isotopes, etc.
•Mechanics: excessive weights, sharp instruments or
cutters, etc.

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Sanitary Processes Models of Health Systems30

Electrical.
•Climatic: temperature, ventilation, and humidity.
b) Chemicals: Medications. Chemical products. Reagents.
c) Biological. Bacteria. Fungi. Viruses. Parasites.
d) Psychological. Excessive work. Stress. Job dissatisfaction.

2. Prevent risks. Implement suitable facilities, equipment and

safe working methods, and have sufficiently skilled personnel
trained and educated for their professional competence.

3. Protect against risks. Since it is impossible to eliminate all

risks it is necessary to address protection tasks. This implies trying
reduce staff interaction with potentially hazardous situations
dangerous, as well as the signaling of potential hazards and the
adequate protection of personnel.

5.2. Prevention Services

The activities of protection and prevention of occupational risks

carries out a prevention service. The prevention service is the
set of people and material means necessary to carry out the
preventive activities that ensure the appropriate protection of the
safety and health of workers.

In the healthcare field, these prevention services are located in the

hospitals. They are of recent creation, as it was necessary to comply with the
Resolution of March 4, 1999, of the General Directorate of Labor
(BOE No. 71). The prevention services are intended to care,
from its different aspects, of the safety and health of all
workers of the corresponding Health Area (the Hospital of
reference, the Specialty Centers and the Care Centers
Primary)

The objectives of these services, also called units of

occupational risk prevention, consists of a) analyzing all those
factors related to the job position that involve a
real or potential risk to our health, b) implement measures
preventive or corrective measures for these possible risks, monitor their
compliance; and more importantly, to inform and educate everyone
worker for self-care, and, finally, c) to follow up
Continued health status of the workers in the Health Area.

They are usually organized into four main areas:

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HEALTH PROCESSES Health System Models31

Surveillance and Control of Health.

Medical examinations of workers at the beginning of the
work activity.
Periodic medical check-ups for workers with the
application of specific ministerial medical protocols by
Risks (biological agents, data display screens,
manual handling of loads, awkward postures, movements
repetitive, pressure neuropathies...
Response to biological risk accidents (inoculations
accidental)
Action in the event of workplace accidents.
Assessment of the return to work after an accident
of work that generates temporary incapacity.
Action in response to occupational diseases: assessment,
recognition and declaration.
Medical assistance and follow-up.
Vaccination and passive prophylaxis: hepatitis B, hepatitis A and
combined; flu, triple viral, chickenpox, tetanus-diphtheria, and whooping cough.
Tuberculosis surveillance system for healthcare personnel.
Assessment and monitoring of workers sensitive to risks.
Carriers of biological agents.
Pathology that interferes with work activity.
Specific programs: Monitoring program of the
pregnant worker in the healthcare field. Program of
latex allergy monitoring in the healthcare environment.

2. Occupational Hygiene.
•Registration of chemicals with their technical data sheets
security.
Surveillance and control of security booths, self-service kiosks and
auto paint machines.
Assessment of monitoring results, anesthetic gases, etc.
•Monitoring and control of clean rooms at the Hospital (Cytostatics and
Nuclear Medicine.
Evaluation and control of noise and thermal environment.
•Ionizing/non-ionizing radiation (collaboration with the Service
of Medical Physics).

3. Occupational Safety.
Evaluation and control of the risk factors related to
occupational safety.
Registration, research and analysis of workplace accidents.

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SANITARY PROCESSES Models of Sanitary Systems32

•Implantación y seguimiento de los medios de protección

(individuals and collectives).
Registration of hazardous products.
Surveillance of facilities, equipment, and work tools.
Surveillance and control of safety and health signaling in the
work.

4. Psychosociology and Ergonomics.

Assessment, monitoring and control of ergonomic risk:
workload, manual handling of loads, mobilization of
patients, working postures, etc.
Job evaluation and advisory services in the
conception and design of them, as well as in the implementation
of ergonomic equipment, mechanical aids, etc.
Workshop for the prevention of musculoskeletal disorders.
Assessment of psychosocial risk factors:
mental load, job content, personal relationships, etc.
Assessment and intervention in psychosocial risk: stress/burnout,
mobbing, etc.
Evaluation of job satisfaction.
Intervention in conflicts.
Stress management programs.

5.3. Applicable regulations.

The legal regulations on safety and hygiene in healthcare centers are

resume below:

The Law on the Prevention of Occupational Risks 31/1995 of 8

November establishes the general principles to which it must submit.
the Health Surveillance of workers, and constitutes the basis
current regulations that support this activity.

Article 10 regulates the actions of the Administrations

Competent public authorities in health matters
Article 14 establishes the right of workers to the
monitoring of their health status, as well as the employer's duty
to guarantee that oversight.
Article 22 establishes the conditions to which this
Health surveillance must submit to:
Article 23 states, among other aspects, the duty of
entrepreneur to develop and keep available for the
health and labor authorities, the documents that certify
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HEALTH PROCESSES Health System Models•33

the practice of health monitoring of workers

and the conclusions obtained from them indicate:
Article 25 refers to the protection of workers.
especially sensitive to certain risks
Article 26 refers to the protection of motherhood and was
modified by Law 39/1999, of November 5, on Promotion
of the reconciliation of the family and work life of individuals
workers.
Article 27 refers to the protection of minors.
In Article 28, the right of the
workers with temporary or fixed-term employment relationships
determined, to a periodic monitoring of their health status, in
the terms established in Article 22 and in its regulations
development.
Article 31, which regulates Preventive Services, states that
multidisciplinary nature of them, as well as their necessity
training to ensure health surveillance of the
workers, in relation to the risks arising from work.

2. The Royal Legislative Decree 1/1994 that approves the Consolidated Text
of the General Law on Social Security and remains in force establishes the
specific regulations for occupational diseases and the
Responsibilities for lack of medical check-ups.

3. The Royal Legislative Decree 5/2000 of August 4, by which

approves the Consolidated Text of the Law on Offenses and Sanctions in
the social order, points out serious offenses and very offenses
serious issues concerning safety and hygiene at work.
4. The Regulation of Prevention Services, R.D. 39/1997. This
Regulation, develops:
• In its Article 15, the organization and means of the Services of
Own Prevention.
In its Article 17, it develops the requirements for entities.
specialized to act as Prevention Services.
In its Article 18, it develops the material and human resources of
the specialized entities that act as Services of
Prevention.
In its Article 37, it develops the functions of higher level of the
Prevention Services, and in its section 3) refers to the
surveillance and control functions of workers' health,
establishing that they will be performed by healthcare personnel with
technical competence, training, and accredited capacity with
compliance with current regulations.
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SANITARYPROCESSES Health System Models34

5. Specific regulations. Following the development of the Law of

Occupational Risk Prevention and the Regulation of Services
of Prevention, specific regulations have been emerging that create
references to the Health Surveillance of workers exposed to
certain risks.
• Manual handling of loads. R.D. 487/1997, of April 14.
Data display screens R.D. 488/1997, of April 14.
Biological agents R.D. 664/1997, of May 12.
Carcinogenic agents R.D. 665/1997, of May 12.
Chemical agents R.D. 374/2001, of April 6.
Ionizing radiations R.D. 783/2001, of July 6.
6. Other Specific Regulations prior to the Prevention Law
occupational risks. They remain in force at the present time:
Asbestos. Order of October 31, 1984. BOE of 7 of
November 1984.
Noise. Royal Decree 1316/1989, of October 27.

6. BIBLIOGRAPHY.
CORELLA, J. M.; del VAL-PARDO, I. Health systems.
Diagnosis and planning. Díaz de Santos Editions. Madrid,
2001.
• LLANO SEÑÁRIS, J. Health Management. Innovations and
Challenges. Edt. Masson. Barcelona, 1999.
•LÓPEZ, G.; PELLISÉ, L.; GARCÍA, A. The control of spending
sanitary. The participation of professionals and users
Publishing house. Barcelona, 2001.
PIÉDROLA, G. Preventive Medicine and Public Health. Masson-
Salvat. Barcelona, 1991.
SÁNCHEZ BAYLE, M. New forms of management. Foundation
Alternatives. Madrid, 2004.
•TEMES, J. L. National Health System in Spain. Editorial
McGraw-Hill. Madrid, 1997.
•TEMES JL. Hospital Management. 3rd Ed. McGraw-Hill
Interamericana. Madrid, 2002.
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