The GOVERNANCE of the health system with regard to COVID-19 relates to pandemic response plans and the steering of the health system to ensure its continued functioning. It includes emergency response mechanisms, as well as how information is being communicated, and the regulation of health service provision to patients affected by the virus.
On April 28, the Prime Minister made public the de-escalation Plan. Building on the principles of public health protection, minimising individuals’ health risks and preservation of the national health system response capacity, the strategy will be gradual and asymmetric across territories and coordinated along with the regional authorities. Importantly, the strategy will be adapted, if needed, in accordance with the evolution of the epidemic and the impact (positive or negative) of the measures taken at each stage (https://www.lamoncloa.gob.es/consejodeministros/resumenes/Documents/2020/PlanTransicionNuevaNormalidad.pdf) (see Section 1.2 for details on the Plan).
The decision for a territory (that is, province, island or healthcare area) to start off the process and the progression across stages will lie on the achievement of several criteria referred to the epidemiological situation and the health system capacity. Regional authorities should send this information to the Minister of Health one week before the decision has to be taken (https://www.lamoncloa.gob.es/consejodeministros/resumenes/Documents/2020/28042020_Anexo%20I%20PANEL%20DE%20INDICADORES.pdf; Order SND/387/2020 https://boe.es/diario_boe/txt.php?id=BOE-A-2020-4792; https://www.lamoncloa.gob.es/serviciosdeprensa/notasprensa/sanidad14/Documents/2020/08052020_Criterios.pdf). Indicators used for this purpose are:
-Epidemiologic indicators: general outbreak indicators (e.g. number of hospitalisations, ICU hospitalisations, death toll or PCR tests); indicators on public health capacity (e.g. number of professionals doing COVID-19 surveillance) and specific de-escalation indicators assessing the effectiveness of early detection of new cases, isolation and control of contacts.
-Health system response indicators: acute-care hospitalization and ICUs’ occupation rates for both COVID-19 and non COVID-19 patients; sufficient available stock for personal protective equipment, PCR tests, or antiviral drugs, and ventilators; assurance of labs capacity; and, availability of premises easily adaptable as medical centres.
In addition to this set of indicators, health authorities will also monitor the population’s mobility (e.g. mobility index within and across provinces or municipalities or public transport use in the most populated cities) and the socioeconomic situation in each territory (e.g. number of workers or self-employed, number of contracts temporarily suspended (ERTEs) or energy supply consumption).
Decisions made by the national and regional authorities at the different stages of the COVID-19 crisis, from the inception to the transition measures, are following or are adapting the provisions from the international competent bodies such as WHO and the European Centre for Disease Prevention and Control (ECDC).
Since March 14, when the lockdown started off in the country, mobility and labour activity have been severely restricted and subjected to enforcement and punishment. The transition plan has been designed to restore normal life in a progressive way, minimizing the risk of epidemic relapse. This plan includes progressive measures some of which are mandatory (such as the use of face masks in public transports), while some others are strongly recommended and rely on individuals’ responsibility (e.g. maintaining physical distance).
Since May 26, the analyses, recommendations and decisions provided by the Ministry of Health to the Autonomous Communities with regard to the de-escalation progress can be found at: https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov-China/planDesescalada.htm
On July 16, the Ministry of Health and the autonomous communities agreed a “Plan for an early response to control COVID-19 pandemic”, where the competence framework and governance mechanisms to face new COVID-19 waves is further clarified.
According to this Plan, the COVID-19 direction committee (created by the Ministry of Health) and the Interterritorial Council (CISNS) will decide on the strategic management for readiness and response to health threats. In the CISNS, the health authorities from each autonomous community, the Public Health Commission, and the Conference on Alert Preparedness and Response Plans (Ponencia de Alertas y Planes de Preparación y Respuesta), under the coordination of the Ministry of Health, will decide the measures to be implemented. This governance mechanism aims at the harmonization of interventions along the territory, whilst directives and guidelines of the Ministry of Health, EU and WHO are taken into consideration.
If any alert signal appears, the Centre for the Coordination of Health Alerts and Emergencies will carry out a risk assessment in coordination with the affected regions. This evaluation will take into account the type of the territory analysed, the epidemiological situation, public health and health system indicators, as well as risk exposure, features of the exposed population and the possibility of implementing prevention and control measures. Once the risk is assessed, specific measures will be taken depending on the depth and breadth of the alert (that is, isolated cases, institutional outbreaks, community transmission or uncontrolled community transmission). The Plan describes specific measures for schools, healthcare centres, social care centres, nursing homes or prisons, as well as for vulnerable populations.
If the situation surpasses regional capacities, co-governance mechanisms will be agreed and coordinated with the affected autonomous communities (https://www.mscbs.gob.es/gabinetePrensa/notaPrensa/pdf/17.07170720140919256.pdf).
On August 4, the Spanish Government reinforced the structure of the Ministry of Health for a better control of COVID-19 outbreaks or new pandemic diseases. For that purpose, a Health Secretary of State was created to support the Minister of Health in the communication of health policies and decisions and to improve coordination and cooperation with both national and international administrations. Additionally, a General Secretary for digital health, information and innovation was also created, aimed to respond to those challenges stemmed from the pandemic related to digital health and information systems, by, among others, enhancing interoperability at national and international level and innovating in data analysis and health data exploitation (Royal Decree 722/2020 https://boe.es/diario_boe/txt.php?id=BOE-A-2020-9020; Royal Decree 735/2020 https://boe.es/diario_boe/txt.php?id=BOE-A-2020-9139, https://www.lamoncloa.gob.es/serviciosdeprensa/notasprensa/sanidad14/Paginas/2020/030820-se.aspx).
In the Interterritorial Council held on September 9, the Ministry of Health and the autonomous communities agreed on a set of measures to reinforce the coordination with local administrations. The Ministry of Health will maintain regular meetings with the Spanish Federation of Municipalities and Provinces (FEMP), while regional health authorities will strengthen the communication with local authorities sharing relevant information about the evolution of the pandemic, to evaluate their situation and jointly take appropriate control measures (for example, to ease the use of public facilities to those needs stemmed from the pandemic) (https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=5048).
On November 4, the Government presented a summary document gathering all the actions and interventions implemented in Spain since June 21, when the first state of alarm expired. The document describes those criteria, tools, indicators and actions (interventions) shared by all the public administrations, e.g. the common legal framework, the five sets of actions agreed in the Interterritorial Council or the actions taken by autonomous communities under the second state of alarm (declared on October 25). This is a living document which will be continually reviewed and updated according to the evolution of the pandemic and the measures taken (https://www.mscbs.gob.es/gabinetePrensa/notaPrensa/pdf/Estra041120191049195.pdf; https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov/documentos/Estrategia_estatal_segunda_ola.pdf).
On May 4 2021, the Spanish Government issued a Royal Decree Law aiming at speeding up judiciary ratification of control measures decided by the regional governments affecting fundamental rights (i.e. curfews, local confinements, limitations in mobility and gatherings) once the second state of alarm expires (May 9). So, the Regional Courts of Justice have to render a verdict in 3 days maximum. In addition, if the Regional Court does not ratify the measures, Regional Governments are entitled to appeal to the Supreme Court that will have to sentence in 5 days maximum. Notably, the Supreme Court’s verdicts consolidate doctrine and lay jurisprudence so that eventual new measures are already backed by previous sentences (Royal Decree-Law 8/2021 https://boe.es/diario_boe/txt.php?id=BOE-A-2021-7351).
Since 7 January, 2020, when COVID-19 was identified as the pathogen that caused the outbreak in Wuhan, the Ministry of Health, throughout the Centre for the Coordination of Health Alerts and Emergencies (CCAES, in Spanish), activated the COVID-19 protocol in coordination with the Departments of Health in Spain’s 17 Autonomous Communities.
On 4 February, the Inter-territorial Council of the National Health System (that is, the highest governing body in the health system) established the basis of collaboration between the national and regional health authorities, strengthening the coordination and surveillance mechanisms of the Inter-territorial Council when dealing with epidemics (https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=4786).
In the following weeks, the Prime Minister summoned the regional Presidents to make joint decisions on the different courses of action to follow, depending on the progression of the crisis. In turn, the Minister of Health holds regular meetings with the regional Ministers of Health.
The Royal Decree declaring the “state of alarm” on 14 March, conferred full responsibility to the Spanish government to implement measures to deal with the COVID-19 crisis. The Prime Minister has delegated competences to the Ministers of Defence, Internal Affairs, Transport, Mobility and Urban Matters, as well as to the Minister for Health, in their respective areas of responsibility, led by the latter. Required operations that do not fall under the competence of any of the aforementioned ministers have been assumed by the Minister for Health (Royal Decree 463/2020 https://www.boe.es/buscar/act.php?id=BOE-A-2020-3692).
The Royal Decree also put all publicly funded health authorities throughout the country (as well as their officials and workers) under the direct orders of the Minister for Health, although regional and local public administrations retain operational management of health services. Furthermore, the Royal Decree mandates the Minister of Health to guarantee territorial cohesion and equity in the provision of health care services.
In order to enhance coordination in the collection of epidemiological information, each regional Health Authority has to report a core set of indicators to the CCAES, since March 15, which includes: epidemiological indicators (e.g. new confirmed cases, differentiating those diagnosed with PCR and those with rapid antibodies tests and those with and without symptoms, cured cases, deaths), utilization indicators (number of admitted and discharged patients differentiating the type of care provider), and supply indicators (number and occupation of beds in ICUs, reanimation units, and workforce available for service, specially ICU doctors and anaesthesiology and reanimation professionals, including 4th and 5th year residency physicians, as well as any other healthcare professional that could be summoned if required, including retired professionals and physician and nurses in their first years of training). They also have to report on protective personal equipment and diagnostic kits needs (Order SND/234/2020 https://www.boe.es/diario_boe/txt.php?id=BOE-A-2020-3702; Order SND/267/2020 Documento BOE-A-2020-3953; Order SND 352/2020 https://boe.es/diario_boe/txt.php?id=BOE-A-2020-4493).