Healthcare: “co-governance” without governance


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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.

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