The book What’s happening with your healthcare system (J. Sevilla, I. Riesgo, Editorial Profit, 2018) is an analysis of our health system, both public and private. It tries to dismantle the thesis that, after the cuts as a result of the economic crisis, a recovery in spending and a reversal of “privatizations” could by themselves fix the problems of the sector. Far from this approach, the authors argue that this would not fix anything, if there are no reforms of the National Health System, which is not threatened by “external enemies”, but by resistance to change and the absence of strategic direction.

The book consists of 6 chapters, the brief summary of which is presented below:

Chapter 1: A healthcare system that lives off the inertia of the past

This chapter talks about the cuts in the 2010-2013 period, how they were made and what consequences they had. It is also said that the system continues to do many things well, including maintaining activity during cuts.

Some changes introduced in this period are also analyzed, such as the supplier payment plan, of extraordinary importance; the cap on the growth of pharmaceutical spending; and, the pharmaceutical copayment for pensioners.

Likewise, it is mentioned that the tsunamic represented in the sector the new medicines against hepatitis C, whose approach is presented as a great healthcare success and a resounding political failure. Healthcare success because it cured many patients –something uncommon in medicine- and political failure, in the absence of an adequate governance system for the introduction of new technologies in the system.

Chapter 2: Private healthcare grows, but not at the expense of the public

During the crisis period, public health spending fell, but private spending rose, but not because there were transfers from public to private, as is sometimes said, since both events respond to different logics.

The chapter analyzes both the private insurance sector and the provider, with their strengths and weaknesses and the challenges that lie ahead.

One of the consequences of the economic crisis is the general reluctance towards public-private collaboration. The business benefit of private companies is discredited, as if that makes them incompatible to provide a public service. These topics are discussed in some detail.

Chapter 3: Health in the world. Typology of health systems

This chapter discusses the origin of health systems and the different agents that operate in them. Mention is made of the history of European systems and American exceptionalism, commenting on what Obamacare and Trump’s approaches meant.

Mention is made that health systems are the consequence of the history, economy and culture of each of the countries. From this point of view, no two systems are the same and there is no ideal system, although some general lessons can be drawn from the analysis of the systems (the important role of governments, primary care as a key in the provision of services, negative effects of payment per act, etc.)

This chapter presents universal coverage as a blueprint for the future for many countries, including the poor; and the need for global governance in the health system, since many problems do not affect a single country, but entire regions or the whole world.

Chapter 4: A system fraught with problems, rigidities and misgovernance

It is based on the basis in the book that there are some problems of the National Health System that have never been solved and that not solving them makes it difficult to tackle new challenges.

The 7 “historical” problems identified are:

• • • Financing
    • Governance
    • Personnel
    • Managers professionalization
    • Autonomy of centers
    • Procurement
    • Evaluation

Health transfers, the most important transformation of the system, have not always meant an impulse to certain changes, on the contrary, in some cases they have even slowed them down, such as in the autonomy of centers, where there was an interesting program underway for the use of the form of public companies, foundations and consortia for the business transformation of the public health sector, something totally forgotten since the transfers.

Chapter 5: A System Unable to Meet New Challenges

Today’s society has nothing to do with the one that existed when public health systems were created at the end of World War II. The population is much older; new diagnostic and therapeutic technologies allow us to do much more than then; there is a predominance of chronic diseases; information technologies enable new healthcare approaches; the population is more demanding and willing to participate.

This means new challenges, which did not exist a few years ago.

The book identifies 7 new challenges:

• • Achieve a commitment from the population in maintaining their own health and in the sustainability of the system
  • Put the patient at the center
  • Orientation to the chronically ill
  • Introduction of personalized precision medicine
  • Digital transformation
  • The challenges of introducing new technologies
  • A clear framework for public / private collaboration

Naturally, it is necessary to match the approach to these new challenges with the historical problems not well resolved of the National Health System.

Chapter 6: The Equation of Change

This reform policy is framed within a more general framework of a National Health Strategy.

Contrary to the cuts in the 2010-2013 period, which were made by Royal Decree-law and without the slightest dialogue with the sector, we believe that the reforms that are being proposed, if we want them to be effective, long-lasting and without rebound effects, have It must be widely discussed and agreed with the different interest groups in the sector (from patient associations, to employers’ associations, through health administrations, unions, professional associations and a long etcetera).

In this context, we propose a State Pact for Health, still aware of its difficulties in the extremely rarefied Spanish political climate, characterized by the consequences of the economic crisis; the crisis of bipartisanship, which characterized the long reign of Juan Carlos I; the emergence of new parties, some with anti-system overtones; and the exacerbation of the pro-independence positions in Catalonia. However, it is in times of crisis that certain consensus is necessary.

Achieving this State Pact for Health will depend on two things: finding the moments of opportunity in the general political framework and on reasonable, viable and possible proposals from the sector. Proposals of these characteristics have not always been made from the sector.

In short, a book for discussion. Nobody, in these matters, is in possession of the truth.