Strategic health. Reflections from lockdown

Strategic health. Reflections from lockdown

Where do we come from?


Since William Beveridge started the National Health System in the UK in the year 1948, what we know now as state of well being changed its meaning, the multiple European States have incorporated in their own budgets the necessary economic means to sustain, not only the universal attention system for health, but also, for free and compulsory education for citizens and to sustain also some other social rights (unemployment secure, pension and other types of assistance for people who needed). This three concepts are the base for the state of well being.


Due to the economic crisis of 2008 the European states, under pressure of the European Commission, had to make cuts on the budgets, where these cuts has to be done were not specified, but…


In Spain in that moment the Partido Popular was running the office and decided to make cuts reducing the state of well being. This affected in a special way to the public health. It has to bear in mind that in that time the PP had as a main objective to encourage the private health system (he did it first in Valencia and later in Madrid), and with that end, nothing better than reduce the budget on public health system (and due to that, the subsequent reduction of the quality of that system) to convince those citizens with enough economic means, to jump to the private system or at least coordinate both of them, making health a bigger enterprise.


It is also worth noticing that the health system was something already in the hands of the autonomous communities so, we can say, the Partido Popular was not alone; in Catalonia CiU (another party) took the initiative on the reduction of the health system, even before than Valencia and Madrid, and was the first in encourage the private system.


This reduction policy had as a main objective, to save costs and produce benefice. This was made by a reduction of human capital (not reposition of retirement task) and material (diminished the buy and stock). Due to that, the pandemic has caught us empty-handed.


Let’s see some data comparing countries internationally to support this idea:


Since 2009 and the two following years, all European countries reduced their health expenditure (for example, Germany passes from a 9,3% of the GDP to a 8,9%) but from 2011, Germany, Furnace, Belgium and the UK have being reinstating and even surpassing the GDP they had before, and the beginning of the crisis (Germany is spending nowadays 9,5%).


In this same period, Spain as well as Italy, has been continuously reducing without recovering from this fall. (in Spain before the crisis we spent 7% of GDP and we are spending 6,2% nowadays).


Spain has the sad honor of being, along with Greece, Island and Portugal, one of the countries which has reduced the most on health system in which did not recover from it, according to Javier Ruiz’s article “Has Spain the best health system in the world?”


Vicente Matas from the Colegial Medic Organization, evaluate the total amount of health cut in 8.636 million of euro, that represent a 12,2% of the fall and add on the primary attention, this reduction have been harder, reaching the 16,2% (1.742millions of euro).


Let’s see now some comparative data give it by the OECD in the report “Annual Growth in Health Expenditure Per Capita”:


Global expenditure: Germany 6000 Euros/inhabitant; France 4900euro/h; Spain 3300euro/h.


Heath personnel (doctors+nurses+auxiliary): Germany 71 for each 1000 inhabitants; France 60 and Spain 30,1


The date makes it worse if only comparing the nursing personnel: Germany 13 units for 1000 inhabitants. France: 11 and Spain 5,7. Meaning that being truth the number of doctor of Spain is in line with the number in other European countries, in the case of nursery is scarce, having deficit.


Lastly, let’s see another sector which have been essential in the response to the pandemic: the number of beds in the ICU of the hospitals (rooms with all the necessary sanitary material): if we take as number of beds in Spain base 100, in Germany there are 222 in France 122 and in Italy 133.


We can conclude that ten years of cuts in our country had harmed the system.



Where are we now?


In this moments in which the pandemic caused by coronavirus is freely flying all over the world (and obviously Europe and Spain), in our country this has caught us with a pretty thin health system, that is why we must take a step and start considering the health system not only as a main element in the state of well being but also as an issue of country strategy.


The cuts of the health system in Spain (and in other European countries) have meant a huge reduction in the personal (doctors, nurses, assistants) and material (elemental protection material, beds, ICU’s, breath assistant machines, detection elements, laboratories with capabilities to process test…) means.


What supposes to make health system as an issue of country strategy?


On the one hand, self-dependence form another countries, on investigation, fabrication, storage and distribution of all type of essential sanitary material to surpass this emergency and those which will come in the near future, because as is said in the Global Preparedness Monitoring Board (GPMB) of the WHO and Global Bank, this (or a similar situation) will happen again.

In the last annual report (2019) about global preparation for sanitary emergency named “A world in danger”, alerted of the danger of the pandemic, which could kill between 50 and 80 million of people all around the world and affect to 5% of global economy.


The report, encouraged the countries to invest in the preparation for sanitary emergency and recall that in many situations the panic appears when the emergency is happening and once is overpass we forget about it. This report highlight the data that between 2011 and 2018 have been 1483 epidemics in the world, some of them became pandemic.


Lastly, the report made a prediction: “It presaged an era of increased frequency of epidemic outbreaks with dire consequences and very rapid propagation that will be very difficult to manage”



Where are we going? What should be done?


There is no doubt we have to be ready to face the future.


Having in mind the concept previously mentioned of strategy health system, let’s see what is, from my point of view, what could be done among many other things.


It would be necessary create something like a national enterprise of health with the four elements previously mentioned (R&D, production, storage and distribution) to assure the almost total self-dependence from the international market. In this enterprise the economic criteria couldn't be a priority (for example: it is sure than in China and India the so needed masks would be cheaper than those produced by this national enterprise, but not for that we should depend on foreign enterprises in critical moments, because these wouldn't assure the supply neither the quality, nor the cheaper price because market speculation would automatically act).


All that has been said until now, could be seen from Europe as a winning in many issues thanks to the scale economy, but the urgency of running the project, blocked the 27 countries to agree on the idea of the European dimension.


Maybe later a giant enterprise could be created (such as AIRBUS or ESA) which, in a decentralized way from countries and a perfect distribution system, guarantee the needed supply to all countries.  With that it could be secured that Europe would be in conditions to face emergencies of this kind in any country or in all of them at the same time, as is happening right now.


And having imagination...  Why not "scale up" the solution on a global scale?


The invention would be create and manage a giant enterprise in the scope of the UN. Nowadays WHO exists and it has an important role but very limited. The first thing that should be done would be the creation of a tax at a global level and managed by the UN to finance all the task that this giant enterprise would make: research and develop, production and managing, and which guarantee the supply of all the necessary human and material resources in any country which precise it.


There is a word which is absolutely necessary to address any solution to the huge problem we are facing, in whatever level (national or international), to put in place the actions to make. This word is tax, which means, face the problems trough a just taxation system.


This question will affect initially to the politicians, everyone, those who want to raise taxes and those who want to decrease them; but not just them. This will affect also to society as a whole. We, citizens, have to raise our conscience of the tax system, in an ethical way to prevent and condemned fraud (the polls detect a very low level of fiscal conscience in the Spanish population). In our country the estimations made of fraud, of all types of fraud (evasion, underground economy, tax heavens) raise the number to 60 euro billions as “not collect taxes”. Only with half of that quantity many things could be done.


Finally, indicating a modest suggestion that something reflected in this document, could be considered on the White Book promised by the President in one of his first interventions on the Congress. The work that has compelled in that Book will have to be essential to making measures for the future, basing on an exhaustive analysis of the previous situation and locating responsibilities and responsible persons.


Luis Zurdo, Justice and Peace of Madrid