Last December, we presented a long-awaited report to the Plenary Session of the Interterritorial Council of the National Health System (CISNS), which had been delivered to the Ministry of Health in April 2023, just a few weeks before the first election of the year. It was the one announced “Evaluation of the performance of the National Health System in the face of the COVID-19 pandemic”, which was commissioned from us in 2021 by the CISNS. In just over a hundred pages, we summarize the lessons learned from the most important health crisis we have ever known. Proof of its importance is that, throughout the first five pandemic waves (the period to which the analysis is limited, which runs from 12/31/2019 to 10/13/2021), almost 5 million were registered according to official sources. of confirmed cases, 431,891 hospitalizations, 41,138 admissions to Intensive Care Units (ICU) and 87,080 deaths. Furthermore, the economic slowdown resulting from the pandemic caused the Gross Domestic Product (GDP) to decline to levels close to those of 2016.
The report adopts an essentially propositional approach. Its objective is not to blame any institution for the errors that could have been made in a situation in which it was impossible to do everything right. In some cases we should not even talk about errors, since some actions were the product of previous deficiencies in the system that did not give the option to do anything else. On the contrary, the ultimate goal of the evaluation has been to learn from experience, and offer useful information that guides decision-making to strengthen and unite the SNS and make it more resilient in the face of future pandemic threats. The methodology used in the evaluation follows the lines set by the European Center for Disease Prevention and Control (European Center for Disease Prevention and ControlECDC) and the World Health Organization (WHO) to carry out “After Action Reviews” or Post-Performance Evaluations (EPA) (ECDC, 2020, 2021; WHO, 2018, 2019), and was agreed upon with the CISNS Working Group that defined the terms of the assignment, which established 15 dimensions of analysis structured in three large areas:
- crisis management,
- system capabilities, and
- Information and communication.
The Report has been the result of an intense collective effort, in which hundreds of people have participated who have contributed their experience and expert judgment, as well as thousands of citizens and professionals from the health and social health field. Both the analysis and the recommendations it contains have been based on numerous technical reports prepared by the different Public Administrations, and on a set of field work that includes 16 self-assessment questionnaires, 15 focus groups, 60 individual interviews, two population-based surveys. . and three panel-type workshops, in addition to an exhaustive review of the literature prepared after a public call that allowed numerous relevant documentation to be collected, in addition to that collected through the relevant bibliographic searches (see Figure 1).
Figure 1 Methodology
Source: Evaluation of the performance of the National Health System in the face of the COVID-19 pandemic
The final report points out different lessons that we should learn from the experience. The first is that Spain should reinforce its action in international organizations to politically and financially support activities to prevent the next pandemic. We also know that, in January 2020, we were not sufficiently prepared (despite the knowledge that a pandemic was possible), that our legal framework was not adequate to face the health crisis, and that some of the errors in the response to The pandemic was due to pre-existing problems in the health system, among which the distance between public health and care levels, deficiencies in epidemiological surveillance systems, and structurally undersized human resources for the daily activity of health services stand out. public, and the absence of an adequate information system at the national level. The lack of prior protocols in residences for the elderly and other vulnerable groups, and the limited coordination between the health system and social services, are also notable errors that need to be corrected. Added to this are coordination failures in multiple areas (such as in the mechanisms for sharing medical resources between territories), the weakness of the CISNS as an instrument to adopt homogeneous decisions in some cases, and some very striking communication errors.
It is important to recognize, however, that beyond the clearly better aspects there were many important successes in the response to the COVID-19 pandemic. We particularly highlight: the often autonomous, and in some cases heroic, response of health care, public health and socio-health care professionals, as well as the professionalism and dedication of the Armed Forces and the Forces and Corps. of security. ; the excellent vaccination campaign; the creation of a single command at the beginning of the pandemic and the continuous communication that occurs between the central government and the Autonomous Communities; the priority orientation of the science and technology system towards research into COVID-19; the rapid application of information and communication technologies; the implementation of temporary employment regulation files (ERTE) and other social protection measures; the availability of good production, logistics, distribution and communication infrastructure, and the delivery of millions of professionals of essential services; and the permanent communication of the authorities, many independent scientific and professional societies with citizens, as well as the almost immediate and high-quality information provided by the major media.
The full application of these lessons would lead to what we call an “ideal scenario” for facing a new pandemic. For this ideal scenario to become a reality, we make a set of key recommendations:
- Develop a specific regulatory framework for the exceptional health emergency situation.
- Develop the Early Warning and Rapid Response System of the State Public Health Surveillance Network.
- Carry out the drills established in the National Preparedness and Response Plan for health emergencies.
- Establish a strategic reserve for public health emergencies.
- Promote collaboration, in health emergency situations, of the private health sector with the public and civil-military cooperation.
- Develop mechanisms to keep the registry of centers and professional profiles of establishments that are considered strategic in a pandemic updated.
- Strengthen Spanish participation in the ECDC, the Health Emergency Preparedness and Response Authority (HERA), and WHO Pandemic Center.
- Strengthen public health.
- Reorient primary attention towards what is important and strengthen it.
- Increase the flexibility of hospital care, its ability to expand in critical situations and improve its coordination with the rest of the system.
- Strengthen activities to support public health and healthcare.
- Expand human resources and professional profiles in information systems for health management.
- Develop and test advanced tracking applications.
- Adapt social communication during health emergencies to the perceived needs of the population, incorporating the perspective of the most vulnerable groups.
All of these recommendations, and many others mentioned in the Report, are developed through a Roadmap that contains a total of 72 relevant and feasible actions (see Figure 2), which specifies the actors responsible for their development (Who?) and a reasonable time horizon to carry them out (When?). The identification of those responsible for carrying out the different proposals is essential to ensure that the desired measures become a reality. But, in addition, it is necessary: a) to internalize that a new pandemic is not only possible, but probable, in the short or medium term; b) provide the precise means to make such measures credible; and c) develop an annual accountability mechanism for the work and achievements achieved.
Figure 2 Roadmap
Source: Evaluation of the performance of the National Health System in the face of the COVID-19 pandemic
Our work has been governed, from its beginning, by the principle of transparency, with the methodology for obtaining the processed information being in the public domain. We consider, and we convey it to the CISNS Plenary Session, that, in compliance with that same principle, all the reports produced in the evaluation process must be made available to the public as soon as possible (at the time of writing this entry they have not yet appeared in the website of the Ministry of Health). Furthermore, we understand that all the documentation generated contains extremely valuable information that can serve as a basis for further analysis of the health crisis caused by SARS-Cov-2. For this reason, we call to attention to the authorities, with the request that they make public the annexes that accompany the final evaluation report as soon as possible.
Epilogue
The subtitle of the report reads “Lessons from and for a pandemic”, but in view of the virulence of the flu this season and the current situation of the health system, highly stressed by the pressure of care, it is worth asking if we have really learned something from the terrible experience lived. It is not very edifying to witness the partisan confrontation that leads to political disagreement on basic prevention measures. Unfortunately, without the necessary willingness to cooperate with an eye toward the well-being of the population, no report will be able to help us provide better responses to the health threats of today and tomorrow.
