“Since man has been man, pandemics have always accompanied him.” This quote, from Salvador Peiró and Juan and Alicia del LlanoIt is supported by the ‘Plague of Justinian’ of the 6th century, the ‘Black Death’ of the 14th century, smallpox in the 18th century, the ‘Russian Flu’ of the 19th century, the misnamed ‘Spanish Flu’ in the 20th century… and by contemporary public health crises such as those caused by ‘Influenza A’, the Zika virus… and COVID-19.
Representative example of the theory of ‘Black Swan‘ by Nassim Taleb, COVID-19 has had an impact economic and social considerable in our country. However, if there is one area in which the effects have been especially damaging since the beginning of 2020, it is undoubtedly sanitary and health of the Spanish.
Although the evaluation of the management of the audit requested by public health experts and Spanish epidemiologists in ‘The lancet‘Since 2020 it has not yet been carried out, different institutions have analyzed the impact of the SARS-CoV-2 virus on the National Health System (SNS).
It is the case of Ombudsmanaccording to which the pandemic “has put the public health structure of the SNS on the ropes” and “has dramatically highlighted” shortcomings prior to the pandemic itself – some diagnosed since ‘April Report‘- such as the “fragility of hospital emergency services”, the “weakness of primary care” and “too long waiting lists”.
Figure 1. SNS Surgical Waiting Lists as of December 2022
fountain: Data published by the Ministry of Healthwith the highest number of patients waiting since the records were homogenized in 2003, as a representative example of the impact of COVID-19 on the SNS.
In similar terms, the Economic and social Council has highlighted “the lack of sufficiently effective coordination instruments” between the Autonomous Communities that “have highlighted the need to advance this objective to offer rapid and effective responses to situations of risk to the health of the population such as the current one” .
Likewise, from the academic field, Guillem López-Casasnovas considers that “COVID-19 has turned our health system upside down” and that the tensions generated by the pandemic have been responded to “with improvisations” and “struggles in coordination and political command in the square.”
Given this situation, and considering the ‘Baumol effect‘, the SNS requires reforms, more incremental than disruptive, but useful in any case to promote the so-called ‘Efficient health care‘.
López-Casasnovas considers that “it is not just about [invertir] more resources”, but “the system should be reoriented”, but in what areas? On what principles? With what objectives?
Among others, a possible answer to the first question is the approach carried out in 2020 by the General Council of Official Colleges of Physicians (CGCOM) to the Congress of Deputies to prepare the opinion of the ‘Social and Economic Reconstruction Commission‘. The CGCOM states that «the pandemic has highlighted the importance of pooling all health resources» and that «the time has come to review the ‘Law 15/1997«enabling new forms of management of the SNS’ in intensity and with all the agents involved.»
Also from the World Health Organization Last January, a document was made public in which the development of public-private collaboration is considered appropriate throughout Europe -including Spain-.
Figure 2. Total health expenditure in Spain in relation to GDP
fountain: Data of the OECD (adapted), with the average total health expenditure in relation to GDP in OECD countries in 2020 being 10.8% (8.5% public – compared to 7.9% in Spain – and 2.3 % private -for 2.9% of our country-).
Figure 3. CC concerts. AA. with private healthcare in 2020
fountain: Data from Ministry of Health (adapted), placing the national average at 6.6%.
However, it should be noted that this development is based on legal certainty, transparency, evaluation, measurement of results, the ‘responsibility‘ and the comparison using ‘points of reference‘, which answers the second question.
From those provided in norms such as ‘Law 19/2013of transparency, access to public information and good governance’, the ‘Law 9/2017of Public Sector Contracts’, and the ‘Law 27/2022of Institutionalization of the evaluation of public policies in the General Administration of the State’, as well as the recommendation made from the European Court of Auditors So that contracts with the private sector are based on “solid comparative analyses” that allow the best option to be selected, it seems at least advisable that an institution in the image of the ‘Independent Fiscal Responsibility Authority’ (Airef) monitors at all times – from the consideration of ‘Hawthorne effect‘- because the legal certainty, transparency, evaluation… referred to are scrupulously complied with and adequately transferred to the ‘tell stories‘of management in the SNS.
Beyond other fines – such as the inclusion of benefits, medicines and technology in the public portfolio intended by the Health Economics Association for years and used as an argument since Government of Aragon last April to request the agency from the Ministry of Health-, the ‘Airef sanitary’ would serve -in terms of Mariana Mazzucato– to balance “the relationship between risk and benefit” in public-private healthcare collaboration, that is, to enhance their coexistence and complementarity at the ‘level’confidence builder‘and ensure a relationship’win win‘effective and tangible.
As postulated Francesc Moreu“is in addressing crises [como la generada por la COVID-19] when it must be used to carry out the structural changes that are needed and that, in conditions of prosperity, it would be more lazy to carry out» by acting «on the hard core of the problems so that when things return to normality, do so on new bases.»
Thus, counting on the European economic resources received to alleviate the effects of the pandemic and in the context of the Spanish presidency of the Council of Europe In the second half of the year, it seems appropriate to make virtue of the need evidenced by COVID-19 and develop a ‘Healthcare Airef’ with its own legal personality and independence and functional autonomy that favors cost-effectiveness throughout the SNS, including the forms . management.
The ‘Airef sanitary’ would analyze all the formulas applied – both direct public management and public-private collaboration – to generate an evaluation culture, evidence, good practices and new modalities adapted to the VUCA reality Delaware aging, chronicity, pluripathology… and resource limitation in which we live and, possibly, will live.
How much’Key performance indicators‘ are relevant and apart from any ideological bias, the ‘Airef sanitary’ – whose design must consider successful experiences from countries such as United Kingdom oh Germany – would mean, in response to the third question, a turning point towards the implementation of optimal management formulas, greater operational flexibility, organizational innovation, new legislation… and, consequently, towards the maximization of results -mainly in health- and towards the sustainability of the SNS.
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