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
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 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).