- AIReF proposes 40 measures to improve the efficacy of public spending within the scope of hospital, pharmacy, outpatient and socio-health centres in Aragon. Specifically, it suggests continuing to foster the use of biosimilar medication and improving the system of registering the purchase prices of medication to ensure more uniform prices
- Working along these two lines and structurally introducing them in the purchase process will ensure that significant gains in efficacy are achieved in the Autonomous Region and that a significant volume of public resources is released
- In order to improve the budgetary and staff policy in non-university education, AIReF proposes to set out the budgetary model in a written document, consolidate the oversight mechanisms that the Region has introduced in recent years and revise the training model of teaching staff
- In its evaluation of the University of Zaragoza, AIReF proposes a new financing model based on three pillars: results-based financing, guaranteeing structural costs and improving quality in different areas of university activity
The Independent Authority for Fiscal Responsibility (AIReF) today published on its website the studies commissioned by the Regional Government of Aragon to evaluate pharmaceutical spending, the staff policy of the Regional Department of Education, Culture and Sport and the current financing model of the University of Zaragoza. The Regional Government of Aragon adopted an agreement at its meeting on March 11th, 2020, at which it requested these studies from AIReF and the institution approved the Action Plan on November 25th, 2020
Public pharmaceutical spending
In this study, AIReF analyses three items of public pharmaceutical spending in Aragon: hospital pharmaceutical spending, spending on medication dispensed by prescription at the pharmacy and spending on medication dispensed at socio-health centres. The items evaluated amounted to a total of €585m in 2020, one quarter of the total health spending and 1.6% of the Region’s GDP. Furthermore, on a cross-cutting basis with these items, it analysed two additional pillars of the different sections: information systems and the training strategy on the Rational Use of Medicines (Spanish acronym: URM).
As regards the item of hospital pharmaceutical spending, AIReF observes that the use of biosimilar medication in hospitals in Aragon still has significant room for improvement, above all when compared with other Autonomous Regions, and proposes to continue promoting its use by introducing strategic planning that prioritises more suitable treatments or with a greater potential for change to biosimilar medication. It also considers that incentives should be introduced for the prescription and use of biosimilar medicines, the training of doctors should be improved and the health results measured. According to AIReF, a strategy to achieve this would lead to savings of between €7m and €10m for Aragon (which will increase as more biosimilar medicines become available), in addition to the €23m recorded from the consumption of biosimilars in recent years, following the strategy defined by AIReF in its previous Spending Reviews on the pharmaceutical spending of the Central Government.
As regards the procurement and purchase of medicines, AIReF has observed that the percentage of medicines acquired in the standard way has risen from an almost token figure in 2018 to account for 56.8% by 2020. The provisional data for 2021 confirm this upward trend. At any event, AIReF asserts that Aragon still has room for improvement and proposes to develop, at a regional level, the Public Sector Contracts Act of Aragon, bed down the centralisation strategy for public procurement, increase the public dossiers processed by hospitals and incorporate dynamic competition mechanisms by harnessing electronic procurement systems.
Lastly, as regards the purchase of medication and price negotiation, AIReF indicates that it has found purchase price differences between hospitals, and thus recommends improving the efficacy of the registration system to ensure more uniform prices. In addition, it suggests that the register is implemented attending to homogenous criteria. It also considers it necessary to improve the integration of the purchasing and pharmacy information systems. These proposals would allow uniform purchase prices to be ensured at all centres, which leads to gains in efficiency in purchasing for the public system that would result in a maximum estimated saving of €14.3m annually – 6.1% of hospital pharmaceutical spending.
As regards the item of pharmaceutical spending on medication dispensed by prescription at the pharmacy, AIReF sees room for improvement in the two particularly important elements of pharmaceutical provision and promoting the Rational Use of Medicines (URM): Primary Care Pharmaceuticals (Spanish acronym: FAP) and those in charge of URM for primary care teams. Specifically, it proposes strengthening FAP through greater involvement in supporting prescribers of pharmaceutical care to patients and in monitoring indicators, working together with management and the different professionals involved in primary care. AIReF also suggests strengthening the figure of the URM manager through the formal definition of common criteria in their election, related to the purpose of their actions, along with the goals associated with their functions, with monitoring indicators and specific incentives, which allows them to free up time in their agenda to devote to their actions as URM managers and to boost the training they receive.
AIReF also proposes to revise the objectives model and incentives for professionals and to introduce oversight and monitoring mechanisms of quality. The actions proposed by AIReF would have a positive impact in budgetary terms for Aragon. For example, an improvement in two of the prescription quality indicators would lead to savings of between €3.2m and €7.3m per annum.
In the last part of the study, relating to pharmaceutical spending on medication dispensed at socio-health centres, AIReF analyses, among other aspects, the medication prescription model for residents and proposes the organisation and standardisation of prescription models in terms of quality. Accordingly, at the socio-health centres that have their own doctor, these professionals would be able to propose prescriptions via digital resources and, in accordance with this proposal, for the primary care doctor to make out the prescription electronically. To improve coordination and continuity of care, AIReF recommends the development of joint action protocols subscribed between the Regional Departments of Health, and of Citizenship and Social Rights, and to improve the SIRCovid tool, among other actions. In order to improve the dispensing of medicines to other centres, AIReF proposes the implementation of an efficient, secure system that is fundamentally geared to quality in the dispensing of medicines regardless of the area where the medication is supplied from.
Budgetary and staff policy in non-university education
In this study, AIReF analyses the budgetary and staff policy of the Department of Education, Culture and Sport of the Regional Government of Aragon. It observes that, in the period analysed, the model did not have sufficient mechanisms to guarantee that the forecasts budgeted for and finally approved covered the teaching staff needs agreed and the education agreements formalised. AIReF proposes to accompany the oversight measures established in the Budget Act of Aragon 4/2020 for financial year 2021 in order to mitigate the deviations with coordination and transparency mechanisms.
In this regard, and as occurs with other General Government sub-sectors, AIReF proposes to set out the budgetary model in a written document or manual of procedures, establish a tool or platform that improves access to information, and monitor and control the process by all those involved. In addition, a process monitoring committee needs to be defined that verifies compliance with milestones and tasks and that strengthens the monitoring and control of deviations, along with the creation of parallel or “mirror” teams in the Departments of Education, and of the Treasury, to draw up and monitor the budget in terms of staff and to increase the information contained in public budgetary documents.
AIReF also evaluates the current training model for teaching staff following its redesign in 2012 and concludes that aspects exist that could be improved, such as the shortage of human and material resources, the lack of flexibility and demands of the training methods provided for, the lack of incentives, excessive requirements to cover certain posts and the scant capacity to swiftly respond to emerging needs and sudden changes of circumstances.
In this regard, AIReF proposes to revise these aspects taking into account the potential of technologies and platforms that facilitate access to continuous training, making the parameters associated with training methods more flexible (hours, number of lecturers, etc.) and ensuring the ability to cater for training needs while tying in effective performance-based incentives. In addition, it proposes to develop the framework for evaluation based on the criteria and indicators provided for in the planning of teacher training.
The financing model of Zaragoza University
The third study contains the results of the evaluation of the current situation and proposed modification of the financing system for the University of Zaragoza (UNIZAR). The aim of this system, which seeks to tie in financing to results, is to guarantee equal access, sufficient resources for the university and contribute efficiently to improving its teaching and research capacity.
AIReF observes that the main source of revenue of UNIZAR comes from the Regional Government of Aragon (almost 68% in 2019) and that the level of financing it enjoyed in 2008 had not been recovered by 2019. Furthermore, this amounts to less than 1% of regional GDP and less than the average of Spanish public campus universities. Despite this, the regional financing it receives shows that it has received more favourable treatment in recent years than public campus universities as a whole and its peer universities.
In addition, and in contrast to what happens at other universities, the resources it receives at a national level from the Central State Administration (Spanish acronym: AGE), from companies, from non-profit and international institutions to fund its research activities have fallen. For its part, revenue from teaching services has increased, but this has occurred as a result of enrolment price increases and not due to the number of students enrolled, which has only increased in the case of master’s degrees.
In terms of enrolment, the presence of UNIZAR has fallen among public universities, from 4.3% to 2.7% between the academic years 1985/1986 and 2019/2020, due to increased competition and the lack of adaptation of its bachelor’s degree offer to student demand. As regards spending on investment, this university has seen a greater decline than its peer universities and the public university average.
The teaching and research workforce has increased in number since 2008, although the structure has undergone significant changes. According to AIReF, UNIZAR has significant room to improve staff planning, given that the criteria to shape the workforce are questionable in terms of streamlining and efficiency, and given that staff spending is an inflexible commitment. In terms of its research function, AIReF indicates that, despite being one of the main general research universities in Spain, its evolution over recent years has been less positive than the group of public campus universities and its peer universities.
According to AIReF, it is possible that some of the problems detected at UNIZAR are due to its lack of a strategic plan that allows concrete objectives to be defined, action plans to be defined and resources to be allocated efficiently and effectively. AIReF considers that a specifically designed financing system for UNIZAR could contribute to an improvement in the services provided and the adaptation of these to social demands. Accordingly, AIReF proposes a multiyear financing plan based on three components:
- Results-based financing: this is the most important activity in terms of volume and should finance the basic activities of the university (teaching results, research and knowledge transfer) based on results.
- Financing of structural costs: that cover expenses for which the university lacks room to manoeuvre, such as costs stemming from implementing State and regional legislation, and those stemming from the evaluation of the research activity of the Teaching and Research Staff (Spanish acronym: PDI) of the University Teaching Bodies (Spanish acronym: CDU).
- Financing to improve quality in different areas of university activity, which would provide UNIZAR with additional funding to develop strategic projects.