9 strategic proposals for a health system in crisis




On the occasion of the 6th anniversary of the Health supplement of the Asturian newspaper “La Nueva España”, I published, December 15th 2023,  the following article in said supplement, whose PDF can be accessed:


9 strategic proposals for a health system in crisis

9 strategic proposals for a health system in crisis

Logically, both the public and private health systems have to address pressing day-to-day problems. But it is good that they also have a strategic vision of the changes to be introduced in the medium and long term, a kind of long-term vision, which we will summarize in 9 points. All of this from a broad sector perspective: not only the healthcare or public health part, but also the industrial part linked to health products.

  1. Dialogue and agreement

We consider dialogue and agreements between the actors that make up the health system – Public Administrations, various institutions, companies, professional associations, scientific societies, patient associations, etc. – a prerequisite to address the challenges it faces.

This is not a one-time agreement, but rather a permanent framework. On the other hand, we understand that not only governments and political groups must participate in this dialogue and agreement, but also the various actors in the health system must actively participate.

  1. Orientation towards health, to prevent the person from falling ill and reduce the burden of disease

Our health system – like those of practically all countries – is fundamentally oriented towards disease.

We must promote a paradigm shift that reorients it towards health (life habits, eating behavior, physical exercise, etc.). This implies changes in priorities, financing, main actors, professional profiles, etc.

The objective is to reduce the burden of disease, the only way to make systems more sustainable.

  1. However, there will still be patients and they will need care, which must be provided through the most advanced methods of precision medicine

Despite the reorientation of the health system towards maintaining health, there will continue to be diseases and patients, especially chronic ones.

Patients will require care of the highest quality, personalized and precision, compared to the traditional form of clinical intervention that lacked instruments to segment (with current precision) patients.

This medicine will provide precision diagnoses based on multiple analyzes and studies of all kinds, which will allow diseases to be redefined in a finer (more granular) way and, therefore, offer the most appropriate treatment for each pathology.

This will mean more complex and expensive healthcare, which must be addressed.

  1. Human resources policies, a central element

Healthcare professional activity is very demanding, so burnout is a problem in any healthcare system.

This, together with the shortage of certain professionals and the need to attract and retain talent, means that human resources policies (including planning) have a central role in health policies, something they have never had.

The problem, for different reasons, affects both the public and private sectors.

  1. Better financing, but with cost efficiency

Surely our health system requires greater financing, in order to be standardized with the majority of the most advanced countries in the EU and to be able to address certain pending challenges (new human resources policy, digital transformation, precision medicine, among others).

However, this request can only be made within the framework of an effort to achieve cost efficiency.

This requires several elements: first, suppressing a lot of activity that does not add value, including duplication of tests and procedures (in line with the “do not do” initiative, promoted by the Ministry of Health, in collaboration with scientific societies); secondly, facilitate a new management framework that facilitates efficiency and, finally, measure and make public efficiency, by establishing indicators at the national level to measure it.

  1. Hybrid, in-person and technology-based assistance

Although online health activity did not begin with the COVID-19 pandemic, this clearly boosted her.

Healthcare from now on will be hybrid, a percentage will be in person and another percentage, perhaps greater and growing, online. Not only for consultations, but for monitoring, early diagnoses, surgeries, tests and all types of activities.

  1. Collaborative care

We must move towards what we could call collaborative medicine.

This implies greater coordination and continuity of care between Primary Care and hospitals; greater collaboration between the health sector and the social and socio-health sectors; more multidisciplinary care, in which different professionals participate. Finally, as in all advanced societies, the public health service must be offered by a very varied set of public and private institutions and companies, both at the level of insurance and provision.

  1. A “hub” of innovation in biomedicine for Spain

Spain has become a powerhouse in clinical research, something that we have not encountered, but is the result of the effort and taking advantage of favorable conditions created by multiple agents: the health system, clinicians, the pharmaceutical company, the Administration , scientific societies and patient associations.

The aim would be to take advantage of this undoubted success to extend it to basic research and development, understanding development as the placement of products on the market.

  1. Emphasis on expanded strategic autonomy

The COVID-19 pandemic has highlighted the logistical difficulties – and also the high environmental cost – of excessive dependence on health technologies and medicines produced in distant countries, especially Asian ones.

This is why the European Union coined the term “extended strategic autonomy”, wanting to indicate the need to boost production in Europe of many health products.

Spain must join this movement, favoring the production of health products in our country (especially those that are strategic).

Only with a long-term strategic vision will we be in a position to address the problems of a health system – both public and private – in a serious crisis.

7 days in healthcare (September 11th-17th, 2023)



From the point of view of Biomedicine, it is worth highlighting that the famous doctor and communicator Eric Topol publishes an article in the magazine Science about the multiplication of medical applications of artificial intelligence. The number of variables of each individual person (anatomical, genomic, metabolomics, epigenomics, etc.) can only be captured and used in diagnosis and treatment through the use of artificial intelligence. Clinicians must become familiar with these new tools and possibilities.

Regarding Global Health, The Lancet comments on what happened with the mpox pandemic (previously called monkeypox), which triggered a global alarm from the WHO and which today has decreased significantly. UN high-level meeting on tuberculosis, whose mortality has increased recently, after years of decline. The Gates Foundation proposes simple and cheap measures to improve the health of women who give birth, since 800 women globally die in childbirth every day.

In terms of International Health Policy, there is an emphasis on measures not learned during Covid, as global politicians seem to move away from fundamental concerns such as equitable access to vaccines and greater transparency. Alcoholism is a serious and very common disease in the USA, causing around 140,000 alcohol-related deaths each year in that country. It seems that the new medications (Ozempic, Wegovby) now used for obesity may also be useful in alcoholism, by curbing consumption. In the NHS the waiting list continues to grow, reaching historic record levels, which contrasts with Prime Minister Sunak’s promises. Serious problem for the Nigerian government to retain its doctors, since six out of ten intend to emigrate in search of better opportunities. Eurostat publishes the most frequent surgical interventions in Europe. Caesarean sections and cataracts, the most frequent interventions.

If we talk about National Health Policy (Spain), covid infections skyrocket due to the drop in immunity. Spain has 100 million vaccines not adapted to the new strains. However, the public health commission recommends the use of adapted vaccines. Problem for Spain, since these vaccines not prepared for the new strains cannot be sold or donated. Spain takes 780 days to supply the new medications. Apart from the 629 days recognized in the WAIT report, from the time the drug is approved by the EMA until the price and public financing are approved in Spain, another five months must be added for approval by the autonomous communities and it would even be necessary to add delays due to approval by hospital commissions. Cosmetic surgery operations have increased rapidly in Spain in recent years.

In the field of Companies, at the international level, the Strasbourg plenary session supports the plasma law that favors Grifols. At the national level, private hospitals (ASPE) take the Sanitas and Generali alliance to court. Ferrer and Almirall, with very good prospects.


Global Health

International health policy

  • Mexico
    • Abortion, not criminalized in Mexico. The decision of the Supreme Court to reject the law that criminalized abortion opens the door to its legalization, increasing the liberalization of abortion in Latin America (https://www.bmj.com/content/382/bmj.p2060)

National health policy






Sant Joan de Déu Hospital in Barcelona: how to transform a 500-year-old “hospitality” into a global children’s hospital



On July 12, 2022, a breakfast with Manel del Castillo, Managing Director of the Sant Joan de Déu Hospital in Barcelona, ​​took place as part of the “Breakfasts with leaders in the health sector” series, organized by Roland Berger.

The presentation used during breakfast is shown below:

sjd. madrid. iriesgo. jul2022


A summary of the breakfast content is as follows:

Why was it possible to promote a change of these characteristics

All the changes were possible because management tools were available: precisely what most public hospitals in Spain lack.

Many of the things that we have been able to promote (internationalization, global hospital, etc.) could have been done by other public hospitals, but it is impossible without the appropriate management tools (autonomy and legal personality, personnel regime, etc.).

Hospital Sant Joan de Déu is a public hospital, but privately managed, therefore not subject to the management restrictions of most public hospitals

About us

Basic characteristics

  • Maternal and child Hospital
  • University Center University of Barcelona
  • Private non-profit
  • Arranged with the public system

Basic data

  • 320 beds
  • 2,800 professionals
  • 289 million euros budget


  • 25,672 admissions
  • 245,000 visits
  • 165,039 emergencies
  • 3,381 deliveries

The strategy

The evolution

  • 1867, Charitable Hospital
  • 1973 Pediatric General Hospital
  • 2004, Referral Hospital
  • 2012, Global Hospital

Evolution 2004-2021

  • Number of professionals, x 2.3
  • Activity, stable
  • Complexity, +36%
  • Teaching, x10 in terms of number of students
  • Research, x18 in terms of impact factor (IF)
  • Economic income, x3.5

Hospital Sant Joan de Déu accounts for more than half of hospital admissions in the Barcelona metropolitan area. It is the hospital with the highest tertiary activity in Spain.

A significant percentage of patients are international, coming from the area of ​​Russia (37.3%), Europe (12%), Middle East (10%) and Latin America (20.9%).

The hospital receives 10-12 requests for assistance from international patients a day.

Regarding international activity, we believe that Spain as a country is very well positioned to compete in this field, since it offers very good technical quality (comparable to the best) at a very competitive price. As an example, for a treatment of Fallot, the Hospital Sant Joan de Déu charges 25,000 euros, while in any prestigious North American hospital the price is 250,000 dollars.

The center with the highest number of ERN accreditations (rare diseases) in Spain and the 6th in Europe.

Non-Cat-Salut healthcare billing has gone from 3.7 million in 2004 to 28.4 in 2021.

The drivers of these changes


  • Renewal of 80% of middle managers
  • Incorporation of therapeutic innovations: Card-T therapy Leukemia, oncolytic virus for retinoblastoma, etc.
  • Great research support


  • A child never forgets a hospitalization
    • It can be a traumatic event
    • Or a positive experience even in difficult times
  • The keys to this humanistic approach are what are called the 4 Ps:
    • Parents
    • Play (game)
    • Pain
    • Professionals


The bases of this commitment are:

  • Project
  • Values
  • Coherence (equity)
  • Leadership
  • Autonomy/participation
  • Support/recognition
  • Working conditions

Organizational innovation

  • Management model
    • Participatory model
    • Daily huddles
  • Digital transformation
    • Liquid hospital
    • Cortex (command center on the whole of the hospital’s activity, including follow-up of patients at home)
  • Infrastructures
    • Reform plan
  • Income Diversification
    • International activity
    • Fundraising

SJD Pediatric Cancer Center Barcelona

A new building to house this new center, which cost 37 million euros, all of which were obtained through donations.

A mature fundraising model was developed, after some mistakes. The campaign began on February 15, 2017 and in 2022 this center has been launched.

The result of the fundraising was as follows:

  • Micro-donations, 1.8 M euros (6%)
  • Companies, 2.9 M euros (10%)
  • Founding donors, 25.3 M euros (84%)

7 days in healthcare (July 4th-10th, 2022)


From the point of view of biomedicine, to highlight the finding that cancer drugs significantly reduce the mortality of patients hospitalized for covid.

With regard to Global Health, an important WHO report on mental health, the last of said organization on the same subject dates back to 2001. The Lancet publishes an interesting article on road safety: no less than 1.35 million deaths a year and 50 million injuries depend on that security. Compared to what was usual in the years before covid and the war in Ukraine, hunger has grown in the world, moving us away from the Sustainable Development Goals. The development of health systems in Africa collides with the shortage of professionals.

Regarding international health policy, it should be noted that the USA has just bought 2.5 million vaccines against monkeypox. The WHO and the EMA warn of the new wave of covid. New “centaurus” subvariant of covid, originating in India, but already widely disseminated. Biden signs an executive order, in order to protect abortion rights. The United States doubles the use of telehealth since the outbreak of the pandemic.

If we talk about national health policy (Spain), the wave of covid continues to grow, with an increased impact on hospitals. New approved version of the Framework Statute of Health Personnel, which tries to avoid prolonged temporary periods, which was necessary, but consolidating the statutory regime, which we believe is not good news and in line with what the public health system needs , although perhaps the unions. First regulation in relation to nursing prescription, long awaited. Important report from the Platform of Patient Organizations, showing how chronic patients suspend the health care they receive. Javier Murillo, the undisputed leader in the health insurance sector, warns about the risk of disappearance of administrative mutualism (MUFACE model), since it continuously produces losses. The CAPFF, chaired by the prestigious economist Félix Lobo, releases his report, demanding changes in the regulation of the price of medicines in the SNS, to reinforce “legal certainty.”

In the field of companies, FEFE gives us the news that the pharmaceutical industry already sells more in hospitals than in primary care, a great change. The ASEBIO Report highlights the growth of the sector both in business volume and in investments. It seems that HIPRA, the Spanish vaccine against covid, is getting closer to being approved by the EMA.


Global health

International health policy

National health policy



7 days in healthcare (June 20th-26th, 2022)


From the point of view of biomedicine, to highlight the article in The Lancet that shows that the covid vaccine has saved 20 million lives in the first year of its use.

As far as Global Health is concerned, it is confirmed that covid 19 may be wreaking havoc in North Korea.

Regarding international health policy, it should be noted that the WHO has decided not to declare monkeypox an international health emergency. Strong rise in the incidence of COVID throughout Europe. Controversial annulment in the United States of the Roe v Wade ruling that declared abortion a constitutional right. Now abortion will have to be regulated by the States. Serious public health problems are expected, as in the pre-Roe v Wade era, although mitigated by the widespread use of the abortion pill, which can even be purchased online. For the first time in the history of the United States, an agreement is reached to limit, albeit in a very limited way, the use of weapons, with President Biden having signed a law in this regard. Instead, the Constitutional Court declared illegal any limitation on the display of weapons in public, as some States had legislated. More Americans are dying from drug overdoses than ever before. The European Medicines Agency approves the Valneva covid vaccine, the sixth covid vaccine approved in Europe (after Pfizer-BioNTech, Moderna, AstraZeneca, J&J and Novavax).

If we talk about national health policy (Spain), we are witnessing a growth in the incidence of covid, some speak of a seventh wave. Published in the Official Bulletin of the Congress of Deputies the project of equity law. Important statement from the Consorci Sanitari de Catalunya saying that more than the management model, we must focus on quality and results. The National Market and Competition Commission (CNMC) publishes a report on wholesale pharmaceutical distribution, which is considered a boost to the use of generics and biosimilars.

In the field of companies, it should be noted that Alphabet (Google’s parent company) is making a strong investment to become a powerhouse in health. Its fields of action will be: wearables, clinical records, artificial intelligence applied to health and extension of human longevity. The medical marijuana business is making its way.


Global health

International health policy

National health policy



7 days in healthcare (March 28-April 3, 2022)



From the point of view of biomedicine, the publication in Science that completes the analysis of the human genome should be highlighted, which seems to open the door to the therapy of various diseases.

As far as Global Health is concerned, polio reappearance in Malawi is of concern.

As for international health policy, problems with the covid-zero policy in China continue, which has led to the confinement of millions of people in Shanghai. As it happens, many older Chinese are unvaccinated, apparently out of fear. The satisfaction of the British public with the NHS falls to the lowest levels in history. At this rate, the UK is going to lose faith in what is said to be their last remaining religion.

If we talk about national health policy (Spain), we are witnessing a new phase of the pandemic, with cases on the rise and hospitalizations on the decline. The Lancet shows that the consumption of opioid analgesics is higher in Spain than in the United States.

In the field of companies, from the international point of view, the plan of the Cleveland Clinic to build a hospital in the center of London, with a large investment of 1 Billion pounds, should be highlighted, which could herald the landing of hospitals Americans in Europe. In our country, the private equity company KKR will pay almost 3 Billion euros for IVI, the largest fertility company in the world, in what is one of the largest operations of its kind in Spain. IMQ approves the sale of shares (50% of the insurer) to SegurCaixa Adeslas, which was already a minority shareholder in the company. Important announcement by Sanitas to launch its fifth hospital in Spain. It will be in Valdebebas, it will come into operation in 2025 and will have 100 beds, 23 of which are for mental health, which is a very innovative element in the Spanish hospital landscape.





o Many older Chinese remain unvaccinated, many out of fear (https://www.economist.com/china/2022/04/02/why-so-many-elderly-chinese-are-unvaccinated)

o Lockdown in Shanghai, while covid cases rise throughout China (https://www.theguardian.com/world/2022/mar/28/shanghai-to-lock-down-millions-for-mass-testing-as -chinas-covid-cases-surge)

o The FDA allows a second “booster” for those over 50 (https://www.nytimes.com/2022/03/29/us/politics/second-coronavirus-booster-shot.html)

o The CDC lifts the order that prevented immigration during the pandemic (https://www.nytimes.com/2022/03/30/us/politics/immigration-cdc-biden.html)

  • Other themes

o British public satisfaction with the NHS drops to lowest levels since 1997 (https://www.theguardian.com/society/2022/mar/30/public-satisfaction-with-nhs-sinks-to-lowest- level-since-1997)

o The growth of health spending in the USA was reduced, after the pandemic. In 2021 it rose 4.2%, while in 2020 it had risen 9.7% (https://www.wsj.com/articles/us-healthcare-spending-slowed-in-2021-after-covid-19- surge-11648497601)



o New phase of the pandemic: cases on the rise and hospitalizations on the decline (https://elpais.com/sociedad/2022-03-29/espana-entra-en-la-nueva-fase-de-control-de- the-pandemic-with-cases-on-the-rise-and-hospitalizations-on-the-low.html)

  • Other themes

o The flu gets out of control in Spring, it already supposes more hospitalizations than covid in several autonomous communities (https://www.elespanol.com/espana/20220331/descontrola-primavera-supone-ingresos-hospitalarios-covid-ccaa/660934368_0. html)

o The health plan against tobacco will raise its price and will prohibit smoking in cars and terraces, seeking a 25% drop in smoking (https://theobjective.com/sociedad/2022-03-30/sanidad-tabaco-precio- taxes/)

o Spain exceeds the United States in the consumption of opioid analgesics, according to The Lancet (https://www.elindependiente.com/vida-sana/salud/2022/03/31/espana-supera-a-eeuu-en-el -consumption-of-opioid-analgesics-according-to-the-lancet/)


  • International News

o United Health buys home care firm LHC for $5.4 billion (https://www.wsj.com/articles/unitedhealth-to-buy-home-health-firm-lhc-group-for-5-4- billion-11648550701)

o Great bet by the Cleveland Clinic, to build a hospital in central London for 1 Billion pounds (https://www.ft.com/content/c42bc01c-346c-4ae7-a931-4bbf0605e3ec)

o BioNTech returns almost 2 Billion euros to shareholders after the success of the vaccine (https://www.ft.com/content/db1c6786-6707-4d22-bf43-9c7686cbe97b)

o Fresenius acquires mABxscience and Ivenix to accelerate “biopharma” and “medtech” (https://www.plantadoce.com/empresa/fresenius-acquires-mabcience-and-ivenix-to-accelerate-in-biopharma-and-medtech .html)

  • National News

o The EMA begins the evaluation of HIPRA, the Spanish vaccine against covid (https://www.eldiario.es/sociedad/ema-comienza-evaluacion-hipra-vacuna-espanola-covid-19_1_8871634.html)

o The private equity company KKR will pay almost 3 Billion euros for IVI, the Spanish company that is the largest fertility company in the world (https://www.elconfidencial.com/empresas/2022-03-28/kkr-ivi -rma-transition-fertility_3399221/)

o IMQ approves the sale of shares to SegurCaixa Adeslas (https://www.redaccionmedica.com/secciones/privada/los-medicos-de-imq-aproven-la-venta-del-grupo-a-segurcaixa-adeslas-1096 )

o IMED hospitals opens a new polyclinic in Alcoy (https://www.plantadoce.com/empresa/imed-hospitales-abre-una-nueva-policlinica-en-alcoy.html)

o Sanitas will open a new hospital in Madrid, in the Valdebebas neighbourhood, it will be its fifth hospital in Spain and it is expected to open in 2025. It will have 100 individual rooms, 22 dedicated to mental health. Sanitas will be the tenant, the property will be owned by Pryconsa (https://cincodias.elpais.com/cincodias/2022/04/01/companias/1648816602_273605.html)

o LetsGetChecked acquires the Spanish biotechnology company Veritas (https://www.europapress.es/corporate-y-ma/noticia-letsgetchecked-adquiere-100-biotecnologica-espanola-veritas-20220329123245.html)


Healthcare transfers to the regions: a problem without governance of the National Health System




On January 31, 2022, in the Ernest Lluch room of the Congress of Deputies, the document 20 years of the culmination of the process of health transfers in Spain was presented, a document in which prestigious protagonists of the transfers and other analysts participated. The book was sponsored by AstraZeneca and produced by BioInnova.

I had the honor of participating in said book with a chapter entitled Healthcare transfers to the regions: a problem without governance of the National Health System, which appears below

PDF of the article:


Healthcare transfers to the regions: a problem without governance of the National Health System

Health transfers: a long distance race with a final sprint

The first transfers of health care from the Social Security (INSALUD) took place in Catalonia in 1981, therefore during the UCD period in government and before the General Health Law (1986). The global transfer process lasted more than twenty years, although there were two well-differentiated periods, the first, between 1981 and 1994, in which seven communities received INSALUD transfers: Catalonia, Andalusia, the Basque Country, the Valencian Community, Galicia, Navarra and the Canary Islands, in this order. The conclusion was in 2002, with transfers to the remaining ten communities.

The first seven transfers were made in a long span of thirteen years, the last ten in a final sprint of eleven months.

Before the transfers of INSALUD services, surely because they were easier as they hardly had any resources, those of Public Health had been carried out, despite being the most debatable conceptually. The coronavirus pandemic has shown us the limitations of this improvised process.

Always, as it could not possibly be otherwise in such a complex process, the motivation and impetus for the transfers was of general policy and not so much for health reasons. Let us think, as an example, of how important the referendum in Andalusia in 1980 was, which in practice blurred the differences between article 151 of the Constitution, initially intended for Catalonia, the Basque Country and Galicia, and article 143, for the rest of the autonomies. That referendum activated the transfers to Andalusia, made immediately after the initials to Catalonia. Or the will of President Aznar to quickly close the process of health transfers, as has been told by some of its protagonists ([1]).

There are many discussions about whether health transfers were required by the Constitution or not. Although personally I think not necessarily (at least, as it was done, to the 17 autonomous communities), this is a debate that leads nowhere.

Surely, the most important reason for the transfers is that this approach was more consistent with a State of the autonomies as it was being constituted, in which it is logical that the services be transferred.

In any case, transfers are an irreversible process. It does not seem that some statements proposing to return Public Health competencies have the slightest viability, beyond political rhetoric ([2]). Therefore, the logical approach is to try to take full advantage of its potential, minimizing some possible negative elements, of disintegration of the National Health System.

The transfers were made without previously defining cohesion instruments

What do we mean by cohesion instruments? To certain organizations (generally known as Agencies), whose basic characteristics are a certain independence from political power, a high technical and professional level, and extensive participation in their governance by key agents, all with the aim of providing support strong technical approach to certain system problems.

These types of instruments have been implemented in many countries, even in some with highly decentralized health systems.

We refer, for example, to the Agencies for quality and clinical activity ([3]); drug evaluation ([4]); public health ([5]); evaluation of medical technologies ([6]); transparency and dissemination of information ([7]); promotion of e-health ([8]); promotion of patients’ interests ([9]); etc.

The Law of cohesion and quality in 2003, after having completed the transfer process, therefore a posteriori, wanted to address the problem of cohesion. But it did so with some instruments (service portfolio, comprehensive plans, High Inspection) that proved ineffective. Regarding the portfolio of services, an independent Agency was not added to guarantee its updating; comprehensive plans, while interesting, are of limited effect; and, as for the High Inspection, from the beginning it was not a useful instrument, given its rejection by the autonomous communities.

The main problem: the absence of a definition of what are and what are not attributes of the National Health System

It must be taken into account that health transfers are not only an administrative decentralization, but a political “devolution” ([10]), which means that communities must be able to define their own priorities and how to achieve them.

This means that uniformity is not a value of the National Health System, rather the opposite, diversity is a value.

Now, for it to be truly a System, as defined, and not a set of systems, the National Health System must have some common attributes, on which little thought has been given. Even without a rigorous legal analysis, we consider common attributes of the National Health System:

  • Universal coverage
  • Public funding
  • The common service portfolio
  • The mobility of professionals, which implies common training aspects
  • Some elements (not all) of the care model, such as the operation of primary care as a gateway to the system
  • Since the services must be open to the entire population throughout the territory, the sharing of certain clinical information, such as medical records, unless you want to do “anonymous medicine”.
  • Likewise, the implication in certain common decisions of the National Health System, what has now been called “co-governance”.

If all this is common, what is left to the powers of the autonomous communities? Many things: whether or not to prioritize health in the public budget, beyond a minimum that guarantees compliance with the portfolio of services; the portfolio itself, adding or not benefits to the common portfolio; the management model (from this perspective, the intention of the Ministry of Health to declare direct public management as “preferential”, included in the Preliminary Bill of Equity, Universality and Cohesion, in process when these lines are written, seems to us an attack on the powers of the autonomous communities); many aspects of personnel policy (remuneration framework, incentives, professional categories, selection and evaluation process, etc.); elements of the healthcare model itself; relations with the private sector, etc.

What is important is to be clear about the rules of the game.

Transfers and dissolution of INSALUD

It is not only that health services were transferred simultaneously to the ten communities that had not yet received them, it is that INSALUD was also dissolved.

With all its possible flaws, INSALUD was an important technical buffer. These functions were not replaced by anyone, since the Carlos III Health Institute, which could have assumed these functions, never did, beyond supporting research; and the Ministry of Health, very limited in its capacities, was never a technical body, but rather a political one.

Thus, the transfers were made without the communities having a technical body of reference, which is all the more serious since the majority of the communities that received the transfers had less than two million inhabitants and their administrations were under construction, with which its capacity to set up highly qualified technical bodies was more than limited.

Thus, the transferred health services were left to the exclusive discretion of a political leadership, not always aware of the complexities of the health world, which acted without technical checks and balances, an ideal breeding ground for all kinds of errors and wrong decisions.

Positive and negative effects of transfers

Before we get into these topics, we should mention what we don’t think are transfer issues. Sometimes the great differences in health financing of the autonomous communities or the inequities in resources, results and access as a consequence of the transfers are adduced. Nothing more uncertain. These problems were already there before the transfers and it does not seem that they have aggravated them either ([11]).

Among the positive effects, surely a more accurate understanding of the territorial problems of health, very difficult to understand from centralized organizations, which tend to see everything from the perspective of a certain uniformity. Also an incardination of health in regional projects, very important, since health must be framed in health policies, which are intersectoral by definition.

But, along with these positive effects, the negative ones are very evident:

  • We have already commented on the problems arising from the way transfers are made, without the existence of a technical support body, with the consequent dangers of this situation, due to excessive dependence on political decisions not nuanced by solvent technical support.
  • There has been a clear phenomenon of centralization in the Regional Health Services, with a brake on some ongoing movements of autonomy of health organizations (public companies, foundations, etc.) that were stopped cold, accentuating the more administrative features and bureaucratic of the system. The latest unfortunate episode of these characteristics is taking place in Andalusia, where the government of the Junta is dismantling the initiatives of public hospital companies, under the pretext that they were “chiringuitos”, but that conceals a distrust in the slightest autonomy of healthcare organizations.
  • A brake on reform initiatives. An unintended consequence of the transfers is that there was a parking lot for the great pending reform issues (management model, personnel regime, etc.). Let’s say that the Ministry was inhibited, since “everything was transferred” and the communities saw that as problems that did not concern them. The consequence is that many key issues are no longer on the political agenda.
  • Cohesion problems, due to the lack of adequate instruments. The absence of the creation of a general information system of the National Health System; the failure of medical record interoperability; the important differences in quality and results in the different autonomous communities; and, an extreme opacity of the health system as a whole, are just a few examples.

It is good to be aware of these problems, not so much to question the transfers, which seem irreversible to us, but to lay the foundations that allow us to take advantage of their full potential, minimizing their problems and guaranteeing the attributes of the National Health System.

“Co-governance” during the pandemic, although improvised and poorly organized, offers some lessons

During the pandemic, the use of the term “co-governance” became widespread. Regardless of the use of this concept to justify the inhibition of the central government in certain decisions, the truth is that the concept has a basis of truth: the limitations of the Ministry of Health to exercise leadership alone in the National Health System, if it is not by sharing it with other organizations, institutions and groups.

The mistake is to have applied “co-governance” only with governments (those of the autonomous communities, in the Interterritorial Council) and not with the group of agents in the sector. Making a play on words, we could say that there has been “co-governance”, but not governance, as this is interpreted as the participation of the different agents.

But it must be recognized that there is truth in the concept of “co-governance” and that, well defined, it can be a solution.

The false solution of giving executive character to the Interterritorial Council of the National Health System

Faced with the problems of a totally decentralized Health System, some ([12], [13]) propose giving executive powers to the Interterritorial Council, something that it never had since it was always a coordination body, not an executive one.

We believe that the problems of the Interterritorial Council of the National Health System are not the lack of enforceability of its decisions, but rather that of “feeding” its activity with two important “inputs”: those derived from the participation of all the agents in the sector and the information and technical positions from specialized technical bodies.

Giving executive powers to the Interterritorial Council of the National Health System will surely bring more problems than solutions and seems difficult for the autonomous communities to accept.

A forum where the government shares its decisions on the National Health System with the autonomous communities and where both the central government and the autonomous communities receive the “input” from both the representation of the main agents of the system, and the technical bodies seems to us something much more effective than a theoretical “enforceability of their decisions.”

A proposal: strengthen participation and implementation of cohesion instruments

The key element to take full advantage of transfers and neutralize the problems that have been detected is to provide the National Health System as a whole with a well-defined and mature governance model, based on a much greater participation of the different agents and to provide of cohesive organs.

Regarding participation, it would be a question of modifying the composition of the Interterritorial Council of the National Health System, giving entry to it to a citizen and patient representation; as well as professionals, mainly represented by scientific societies.

As for the cohesion bodies, they should be constituted through a multi-agency system, model AIReF (Independent Fiscal Responsibility Agency). At least the following:

  • Information, Evaluation and Quality Agency
  • Public Health Agency
  • Agency for digital transformation

This approach would make it possible to resume a reformist agenda, fundamentally in the two major issues forgotten in the General Health Law: the management model, so that health institutions move towards a more businesslike and less administrative operation; and the personnel system, in order to overcome the rigid statutory model and gradually set up more flexible forms of relationship between professionals and the system.ties


[1] Statements by Rubén Moreno, “Lights and shadows of transferences: 15 years later”, El Médico Interactivo, 3/22/2017, https://elmedicointeractivo.com/luces-sombras-transferencias-sanitarias-15-anos -after-20170322125517110945/ (accessed December 9, 2021)

[2] Vara proposes that the regions return public health competencies to the Government

El Periódico de Extremadura, 10/17/2014, https://www.elperiodicoextremadura.com/extremadura/2014/10/10/vara-propone-regiones-devolven-competencias-44585804.amp.html (accessed December 9, 2021 )

[3] Care Quality Commission, in the United Kingdom; National Agency for Quality Assessment in health and social organizations, in France; Institute for Quality and Efficiency, in Germany; National Institute for Health, in the Netherlands; Agency for Health and Social Services, in Sweden

[4] NICE, in the United Kingdom; Drug Evaluation Council, in the Netherlands; the Agency for Medicines, in Norway; the Agency for Medicines and Dental Products, in Sweden

[5] Public Health Agency, in France; the National Institute of Public Health, in Italy; the Norwegian Institute of Public Health, in Norway

[6] Agency for Medical Products, in Sweden

[7] Agency for information on hospital care, in France; the Institute for Quality and Transparency, in Germany

[8] ASIP Santé, in France; the Swedish Agency for e-health, in Sweden

[9] Healthwatch England, in the United Kingdom

[10] “Devolution” is the term used for this type of transfer to territorial entities with political autonomy.

[11] López-Casasnovas, G, Rico, A

Decentralization, part of the health problem or its solution?

Gac Health 2003; 17(4):319-26

[12] Martínez García, JM

Lights and shadows of the current health decentralization in Spain

Giménez Abad Foundation, June 26, 2019

https://www.fundacionmgimenezabad.es/es/luces-y-sombras-de-la-actual-descentralizacion-sanitaria-en-espana (accessed December 10, 2021)

[13] Appearance of the Collegiate Medical Organization in the Commission for Social and Economic Reconstruction of the Congress of Deputies, 6/2/2020

https://www.congreso.es/docu/comisions/reconstruccion/informes_comparecientes/390_20200602_DC_Sr_Romero_Aguit.pdf, (accessed December 10, 2021)

What if there was another pandemic?



PDF of the article published in La Razón:

La Razón, ¿Que pasaría si hubiera otra pandemia?

On January 31, 2022, coinciding with the second anniversary of the diagnosis of the first case of COVID in Spain, which took place on January 31, 2020 in La Gomera (Canary Islands), the newspaper La Razón published the following article:


What if there was another pandemic?

A great crisis for a new government

The first case of COVID in Spain was confirmed on January 31, 2020, exactly two years ago. The new PSOE-Unidas Podemos coalition government had been constituted on January 7, 2020, therefore very few days before the appearance of the crisis. It was a government of ideological confrontation rather than management, with a precarious and heterogeneous parliamentary majority, which made any parliamentary initiative difficult, and unwilling to reach agreements with the opposition.

Possibly the worst of the political contexts to address a crisis of these characteristics, where technical competence, the ability to promote legislative initiatives and obtain the support of Parliament for certain measures and the achievement of wide-ranging agreements, were key.

Great health and economic impact

With data as of January 28, 2022, obtained from the Coronavirus Resource Center of Johns Hopkins University, Spain is one of the countries with the highest mortality from COVID. With 197.05 deaths per 100,000 inhabitants, excluding a few countries, such as the United States, Belgium, Italy and the United Kingdom, most of the developed countries and almost all European countries had lower mortality per 100,000 inhabitants than Spain. We refer to France, Portugal, Austria, Sweden, Luxembourg, Switzerland, Germany, Ireland, Canada, Holland, Denmark, Finland and Norway, to name just a few.

But it is that in economic impact Spain also stands out. In a recent report by The Economist published on January 1, 2022 and in which the evolution of different economic indicators during the pandemic in 23 countries is compared, it is concluded that some countries have performed especially well, such as Denmark , Norway and Sweden; United States reasonably well; other European countries such as the United Kingdom, Germany and Italy, clearly worse. But the worst of all was Spain.

Two phases in the management of the pandemic: from “single command” to “co-governance”

In its initial phase, there was too much trust in the well-known strengths of the Spanish system, some weaknesses of the system were not taken into account (such as the precariousness of Public Health), there was a late reaction, we faced serious problems in purchasing material , there was a high number of infected and dead professionals. For a long time we witnessed a shortage of tests and there was no general approach to carrier detection or tracking of those affected and there was a lack of special approaches for risk groups.

In the first wave, the Ministry of Health is awarded the “single command” of the crisis, based on the state of alarm. But this Ministry had been almost irrelevant for decades and had a weak management capacity, as evidenced by the purchases that it initially intended to address in its entirety. Nor did it articulate a dialogue and participation with the different protagonists of the sector. Serious problems of the information system were evident. The communication policy was not always successful.

Having overcome the state of alarm, in the rest of the waves, the government learned the lesson of the high costs of managing a crisis of these dimensions, and went from being the protagonist to being almost inhibited, improvising a so-called “co-governance”, which in the practice consisted of holding regular meetings with the autonomous communities, leaving almost all decisions in their hands, including some that, because they affected fundamental rights, were later annulled by the judges. Then “co-governance” without governance was invented, since the only interlocutors were governments, but not the rest of the groups, agents and protagonists of the sector, as governance is understood.

When the time came, everything was trusted to the success of the vaccination, which was shown to be an error in the face of the new “ómicron” variant.

Even with very high figures for COVID, both the Government and the SEMFYC are committed to “influenza-like approach”, that is, downplaying COVID by considering it similar to the flu, something rejected as premature by both the WHO and the European Union. It is hoped that COVID will become “endemic”, as if, for example, the malaria endemic had not caused 600,000 deaths in 2020.

What if there was another pandemic?

It seems clear that the pandemic is not an exceptional or unrepeatable event, what is usually called a black swan, but rather we live in a world where, in the last two decades, there have been epidemic outbreaks every three years (SARS, H1N1 avian influenza, MERS, Ebola, Zika, etc).

What would happen if, as Bill Gates warned last week or some virologists like Christian Drosten, a new pandemic arrives?

It would happen that the problems that we encountered two years ago have not been resolved: the Public Health Center that is announced does not respond to the approach of an independent Agency proposed by SESPAS and many other groups; governance of the health system has not been addressed; nor the participation of professionals; nor the relations between science and political decision makers; nor the information system; and, surely neither essential supplies. Everything is entrusted to the arrival of “Next Generation” funds, but without addressing the necessary reforms.

Healthcare: “co-governance” without governance


See PDF of the article:

Sanidad: «cogobernanza» sin gobernanza

Article published in “La Razón” on December, 24, 2021.

During the pandemic, the use of the term “co-governance” was generalized. Regardless of the use of this concept to justify the inhibition of the central government in certain decisions, the truth is that the idea has a truth fund: the limitations of the Ministry of Health to exercise solo leadership in the National Health System, if It is not sharing it with other organisms, institutions and collectives.

The error is to have applied the “co-governance” only with governments (those of the Autonomous Communities, either in the Interterritorial Council or at the Conference of Presidents) and not also with the set of agents in the sector. Making a game of words, we could say that there has been “co-governance”, but not governance, as this is interpreted by the participation of the different agents.

The National System of Health needs a governance model, particularly after transfers and especially after its generalization in 2002, which were done without the previous creation of cohesion instruments, as well in other countries, also with very decentralized health systems. The Law of Cohesion and Quality of 2003 tried to introduce, a posteriori, some instruments of cohesion, but these were ineffective.

When we talk about governance, we refer to the decision-making process, especially in complex organizations such as the National Health System, where it is necessary to take into account two apparently opposed values: the preservation of general features of the system, which identifies it as such , and, at the same time, respect for the exercise of political autonomy in health by the Autonomous Communities.

In this complex framework of governance, it is necessary to ensure at least two things: an involvement of all agents of the sector (patients, professionals, companies linked to the sector, etc.) and having a permanent advice on very complex issues based on criteria of high and recognized technical and professional level. This is what in other countries have resolved with the creation of independent agencies on very varied problems: agencies for quality and clinical activity, medicine assessment, public health, medical technologies, transparency and dissemination of information, impetus to The e-health, promotion of the interests of patients, among others.

In the absence of this governance framework, with pandemic and without pandemic, the ideal culture broth is generated for all kinds of errors and wrong decisions.

Is why it should be proposed to advance in the governance of the National Health System, in the first place, articulating the participation of the different agents at all levels, but very particularly in a renewed Interterritorial Council, of preceptive consultation consultation Decisions And taking advantage of a multi-agency system, AIREF model, at least the following: Information, Evaluation and Quality Agency; Public health agency, and, agency for digital transformation.

This approach would allow addressing a reformist agenda, something absent in the National System of Health for years. Precisely to prepare for possible new pandemics, as well as to rethink the two major themes forgotten in the General Law of Health: the management model, for health institutions to advance towards more business and less administrative operation; and, the personnel regime, to overcome the rigid statutory model and ride more flexible forms of relationship of professionals with the system.

In health always have a lot to say governments. This happens in all countries. This is how it should be like that. Even in the United States, where,  for the first time in its history public health spending has exceeded the private in 2020. But health is not a subject only from governments. It is also a matter of patient associations, scientific societies, academic institutions, of companies linked to the sector, etc.

An improvised “co-governance”, which also comes and goes as the figures of the Covid evolve, designed rather to protect themselves from the wear of certain measures or the absence of them, is not the answer.

In summary, there can be no “co-governance” without mature governance in the National Health System.

Seniority or merits?



Article published in the daily “La Nueva España” (Oviedo), June 2, 2016

Seniority or merits?

These days we are witnessing in Asturias an acute controversy following the incorporation into the Asturias Central Hospital, the largest hospital in the region, of 70 doctors based only on seniority criteria.

The reason for the controversy is that service chiefs have rejected the procedure, considering that the merits and needs of the hospital should have been evaluated, while unions rallied strongly in favour, reckoning that seniority is a good approach and a way to avoid arbitrariness.

I do not intend to fall into primary anti-unionism, but rarely has the negative role that unions have been playing in the public health sector over many years, to the point of becoming a serious obstacle to the necessary reforms, been viewed so harshly. The so-called “professional” unions are no exception, but often even adopt more radical positions. I am obviously not an advocate of the disappearance of unions, but of a union practice that is not incompatible with intelligence and common sense.

But agreeing with the service chiefs does not end the debate, if we don’t consider other points.

First, the statutory regime itself, which assimilates health workers in the public sector to civil servants, hyper-protectionist towards sector professionals. The concept of “tenure” creates asymmetry in professionals / management logic, in favour of the former, which often prevents the slightest management and change implementation. Moreover, the egalitarian culture, linked to the statutory regime, reluctant towards differentiation and individual and collective recognition is also very negative. Like many hyper-protectionist regimes they turn against the interests of those who are to be protected, especially the most active and motivated professionals, giving priority to the interests of the uncommitted. Thus no reform of the public health sector can be envisaged with the statutory regime, which should be declared extinguishable and, respecting vested rights, new recruitments made via the ordinary labour regime. Only then will the concepts of regular evaluation, promotion, career and variable compensation, which are so necessary, make sense within the context of a fully-fledged personnel management policy.

Another element that is implicit in the debate is the autonomy of hospitals and health centres. This is an issue that arose in the 80s and 90s of the last century, but was forgotten about with the healthcare transfers to the regions. With them came the hegemony without limits of the regional ministries and progress towards the autonomy of health centres was shelved. But there can be no modernization of health centres if they don’t have a minimum capacity for certain organizational decisions, personnel and adapting their healthcare offer.

Finally, the issue of governance, which includes a government / management separation. The managers run the company, while the government (council members) ensures that management is correct and that it goes in the right direction. And with the board intervening in the selection, evaluation and removal of the first manager of the centre. Only thus can a fully-fledged management system be guaranteed. A step in this direction is taking place in the Basque Country and in a recent resolution of the Assembly of Madrid.

Seniority or merits? Of course, merits, but only within the context of overcoming the statutory regime, autonomy of institutions and governance that understands the distinct role of government and management.