Aser García Rada: Spain’s healthcare revolution

Aser Garcia RadaSpain’s state run healthcare system, one of the best in the world according to the World Health Organization, is facing a serious threat. In the face of growing privatisation, cuts seem inevitable, especially after the overwhelming victory of the conservative Popular Party (PP) in the latest regional elections on 22 May. Since then the PP have issued countless warnings about the insustainability of the healthcare system, to prepare the population for what they are about to do. 

Over the past year, the private sector, also hard hit by the economic crisis, has continued to take advantage of public funding. The private companies’ goal is to re-establish tax breaks for people who take out private insurance. This will mean taking away more resources from public funds and will further aggravate what is already a difficult situation, owing to the severity of the crisis and inadequate public efficiency policies.

So far few have spoken out against this disastrous drift, while Spain’s health professionals’ organizations, medical societies, and trade unions waste their time trying to maintain their power. They haven´t yet sent a solid message to the public that they will protect the public health care system. “The day when most of the middle class opt for private healthcare will be the end of our state healthcare system, because it will then have become a welfare system,” says Gaspar  Llamazares, president of the Congress’s cross party health committee. And that is where we are heading.

As stated by Tiago Villanueva in a recent blog, in the wake of uprisings in north Africa and the Middle East, an unexpected, peaceful, and exemplary civic revolution is invading Spanish streets and squares, which is also spreading to other countries.

At the Puerta del Sol camp, the so called 15M movement started with a large demonstration on 15 May. The protests are continuing. Though basic demands concern the regeneration of our democratic system and bringing back the power to the people, from politicians, banks, and “the markets,” some specific working groups have been created for the debate and proposal of concrete claims.

The health working group of the 15M is open to anyone, but so far it consists mainly of a broad spectrum of health professionals. We are currently debating four key elements:

1 . Public state run healthcare should be available for all people, regardless of their legal situation, or similar such concerns. That also means re-orienting a system that has so far been focused on dealing with acute diseases. When our modern healthcare system was set up, around three to four decades ago, the population’s mean age was younger, and the main aim was to treat acute diseases, but now the population has grown much older, and there are many more people with chronic diseases, and the system is not well prepared for that. Our hospitals are prepared for acute patients, but are not prepared for having an old man with a brain stroke who has to remain there for weeks or months. The system needs to be changed to a model that will strengthen the role of primary care and should focus on health promotion and prevention.

2 .  Individual and collective active participation in health:  This means improving the evaluation of and transparency in reporting health systems data, and promoting health education so that people take ownership of  their own health and that of their community.

3 . Health is not a business, or something to trade with. Private concerns prey on the public health system. Public resources should be optimised, for example by getting doctors to work evening shifts, which are non-existent in most parts of the country at the moment. We do not accept copayment as a solution, and we demand the implementation of a central purchasing system to cut costs. We want the pharmaceutical industry to be more transparent and better controlled.

4 . “Health in all policies” This is a new demand coming from public health professionals here in Spain, meaning that any new policy that is implemented has to take into account its potential impact on health. Differences in health due to economic, environmental, social, or gender inequalities are unfair and avoidable. Therefore it is necessary that any public policies –such as education, social policy, environment, urban planning, labour and immigration, or economics and finance- analyse, and evaluate the health impacts that they will have on the population before they are implemented.

It would be naive and arrogant to think that the 15M is the solution to all our problems, but in the context of immobility, it is a fresh voice reflecting a general dissatisfaction with mainstream social policies that are contrary to people’s welfare.

Healthcare professionals should play an active and visible role to protect our healthcare system and welfare, and this applies to all healthcare workers worldwide. As healthcare professionals we should set an example to the inhabitants of our country, and our personal interests should not interfere with what we are trained to do: to defend people´s health from any threats. As we undergo budget and social policies cuts, we have the feeling that banks, and “the markets,” are deciding things for us, and forcing  politicians to make decisions that are contrary to the welfare of the country.

Although the problems we face in Spain or Europe are not comparable to those faced in poorer countries—such as hunger, war, or living under tyrannical regimes—our globalised world clearly needs a global change. But that collective change can only be the result of individuals’ decisions and actions. In the Western world many of us seem to have forgotten that our responsibility for the population’s health also entails a responsibility to prevent the deterioration of our healthcare systems. 

“Be the change you want to see in the world,” Mahatma Gandhi said. Everyone knows what kind of change needs to be done, and no one else can take care of the environment around us.

Aser García Rada is a paediatrician at the Hospital Infantil Universitario Niño Jesús in Madrid, Spain, and a freelance journalist.

  • Mr. Alonso

    I read with astonishment this blog for two reasons; first for its content and secondly for the fact that the BMJ Group actually publish such a politically biased article with no verification on the information given in it. The data expressed is entirely the opinion of the author with no resemblance with the actual reality of the situation in Spain.
    It starts with the state of the Spanish Healthcare System. As most of the healthcare systems in the developed countries it´s reaching a point of insustainability and indeed something needs to be done about it. Something that was never done by the present Government, which has been in power for seven years. Can the author espalin that “disastrous shift” mention in his article?
    Now, mixing this with the so called 15M movement is foolish. The author defends some points (in first person) as valid and unquestionable – is he a “camper”? The fact is that the 15M movement has deteriorated into violent acts of anti-system and anti-democracy nature in several cities. Actually, that is how they identify themselves: “anti-system”. What was seen initially as a romantic response from the people, is becoming clearer that has been a manipulated action from extreme left wing groups.
    The information given on political issues across borders can never be objective, but in this case is irresponsible for its lack of veracity.
    Mr. J. Antonio Alonso MSc, FRCS, FRCS (T&O), Consultant Orthopaedic Surgeon, working in Spain

  • Aser García Rada

    Dear Dr Alonso:

    Obviously previous blog is “the opinion of the
    author”, which is actually the idea of a blog. Whether it resembles or not
    current situation in Spain could be, obviously, a matter of discussion. I could
    never say that my opinions are “unquestionable”, and I actually never did.

    I also agree that something needs to be done
    about the sustainability of Spanish health care system. From my point of view,
    what needs to be done has to do mostly with those 4 key elements we have been
    debating in the health group of the 15M (… and with financing the system through
    direct taxes. 

    And I also think health authorities haven´t
    played an optimum work, but not only the national social-democrat Government of
    the PSOE. As you know, in Spain the Autonomous Communities –the 17
    administrative regions of the country- have most competences regarding health
    care, which ties hands of the national health authorities in many fields.

    Those regions -governed mostly by those two
    political parties- have been carrying, especially during the last decade,
    policies directed to win votes, more than to improve people´s health. Most of
    them were crying out loud to be unsustainable in the long term since the very
    beginning they were implemented.

    Unsustainable is, for instance, to build eight
    new hospitals, eight! –mostly through the PFI system- in four years, as it
    happened in the Community of Madrid with a conservative government. No doubt
    this has been a good way to get votes but, in my opinion, it has nothing to do
    with a proper response to health necessities of the population, that have to do
    more with improving primary health care, for example.

    Privatisation policies have been followed by
    “left” and “right” wing political parties, but mostly by the conservatives, who
    will keep on implementing them, which will lead us to that drift I talked
    about. As you may know, in the long run, those new health centres will be much
    more expensive to maintain by the public sector.

    With regards to the 15M movement, from my point of view it has never
    been “a romantic response”. Clearly it has been a political movement -meaning aiming to take part in public affairs – of people wanting to think, debate, protest and act to change things
    as they are.

    Though some violent acts have occurred, those
    have been anecdotic since the whole movement began one month ago. As you may
    know, the 15M has condemned them. A good example of the actual way we work has
    been the demonstrations that took place on June 19th all through the
    country, with thousands of people protesting peacefully in the streets (

    Last, but not least, the 15M is a heterogeneous
    movement, and I consider reductionist to say it only involves “extreme left
    wings groups”. Improving our democratic system cannot be an issue related with one especific ideology. Some people involved in it do consider themselves anti-system.
    Some others, and I include myself here, consider that the system is anti-us.

    For further discussion, join our group. It will
    surely be interesting for all. 

  • Dr L. Fernandez (Londres)

    I have no particular feelings in favour or against a public or private health service as far as the whole population has the right to access health care.
    I agree with Mr Alonso that the post is too political. Dr Garcia Rada doesn’t seem to like the Popular party. Like many other things in life this needs a technical solution, no matter the party that is in power.
    Those who defend the public health service should say how are they going to make it sustainable. It would also be necessary to say how are they planning to deal with the misuse of the service that appears to be free; Spain is wasting millions on this. Third, why are health professionals so keen on sustaining a health service that many patients despise?

  • Dr Monica Lalanda

    Dear Dr García
    As much as I agree with some of the points that you and the 15M movement make about the Spanish Health Care system, you all seem to forget that Spain has got a well consolidated democracy. Shouting in the streets, assemblies and parallel suggestions of change might be necessary in other countries that have different political systems. Our democratic system might not be perfect but has proved to be good enough and can get better.
    You describe the 15M movement as a “political movement”, if that is the case, you guys need to play by the rules, make a political party and stand on the next general elections. This is not the best time in the history of our country to request new rules o a different democracy, it is the time to pull together. A political group needs representation and needs to be voted, people meeting in the streets remain just a group of people meeting in the streets, that’s all. If you become a political party I might even vote for the 15M ideas. So far you seem to me like a confusing group that doesn’t represent anyone and insist on it at every opportunity.
    The Spanish health system is unsustainable by all means; in fact the national media released some scary numbers over the weekend. The debt rises to 15.000 millions € but it is affecting autonomies led by either the socialist or the conservatives in equal terms. Unfortunately it is not only the health system that is collapsing, the whole of our economy is a complete disgrace. Spain doesn’t need a change of democratic system; Spain simply needs a new leading party. The 15M is making a great job trying to dilute responsibilities of who is guilty of this mess.
    You seem to dismiss at the beginning of your blog the fact that “the conservative Popular Party (PP) had an overwhelming victory in the latest regional elections” but you still dare to mention it in quite a threatening tone about what they might now do. This seems to me quite disrespectful to all those millions of people who have actually voted for a change. Do you really believe that a few thousand people shouting in the streets and calling for people not to vote are smarter than the millions who went out to vote and voted for a change?.  Please respect the democracy that took so much effort to get, if you people carry on with this movement you’ll end up causing great damage to the stability of our country and I don’t think it can take much more. Whether you like it or not the PP has been voted by the Spanish people to take things from where they are.
    Huge changes are needed and to finish with the absurdity of 17 different health system should be a priority, I agree. However, there is already a political party (Unión, Progreso y Democracia- UPyD) that is advocating that. Why do you need to invent the wheel? We need national elections, we need a new government and we all need to play by the rules. It is not good enough (even if it has become fashionable) to claim that the system is anti-you, if you want a better country, work for it, fight for it but not in the streets, please. We have grown out of that now.

    Monica Lalanda. Medical writer and A&E doctor in Spain .

  • Aser García Rada

    Dear Dr.


    Thanks indeed
    for your comment.


    We may have a
    “well consolidated democracy” but obviously not the kind of democracy
    people wants. As you know,
    official polls say that Spanish citizens consider politicians the 3rd worst
    problem of the country after unemployment, and economic issues. According to
    those polls, we even consider them a worse problem than terrorism! Just by
    taking that into account, would you really say things are working properly?


    We haven´t
    reached the level of political degradation of Italy -that hopefully also seems
    to be currently changing-, but we are really far away from having a modelic democracy. Though
    consolidated, our democracy is barely 3 decades old and still has to remove its
    napkins to get into adolescence. From my point of view something urgent does
    need to be done and I actually think what we are seeing in the streets is the
    turning point for that change. So far, the 15M has made our Congress to begin
    debating about a Freedom Information Act. Taking into account that Spain is one
    of the very few European countries without it, that is something to be thanked


    When you say
    15M should form a political party, you seem to understand that that would be
    the only way to do politics –again, meaning to be concerned on public issues-,
    which is tremendously reductionist. Civil political actions can be taken through
    many different ways and political parties are just one of them. Fortunately,
    because so far we already know how they work.


    For instance,
    the Catalan Nationalist CIU, who won last regional elections in Catalonia,
    celebrated months ago, have just decided to cut an average of 10% of the budget
    for next year,  mostly affecting health
    and education, while they even said, before those elections, that they wouldn´t
    cut in those fields.


    Following a
    similar pattern, before last regional elections celebrated in most other regions
    last May, no political party said anything about these kind of budget cuts,
    though it would be naive to think that they weren´t planning them. This is what
    the Popular Party would do now, after their tremendous victory in those
    regional elections. And, most probably the same thing would have been done by
    the socialdemocrat PSOE, though they won´t be able because they lost almost


    Regarding the
    15.000 million euros of debt in health public sector you say have been released
    by the media “over the weekend” (the conservative journals El Mundo and La Razón,
    did some good reports on them last weekend), that is nothing new. Those numbers
    have been known at least for the last couple of years and have been released
    from time to time by media of a wide political spectrum, with no big impact in
    public opinion. You may do your own search beginning with the information
    released week after week by my colleague Sergio Alonso, chief editor of the
    health section of La Razón.


    So, why do you
    think that this information has grown much stronger just after the PP won the
    elections, reaching the point of making people understand that those data are
    new and where previously hidden? Easy, because first they want to win, but now they
    need people to believe the system is unsustainable so that no one protests when
    cuts come.


    Of course the health
    care system is not sustainable, as it is conceived at the moment, but changes can
    be done in a different way than they are currently planned –we do need regional
    health services, but we need them to be lead responsibly, not with an electoral
    view, as it has been done so far -, which will lead to a disaster.


    All that makes
    me think they consider us fools, that they are lying to us, and that they are
    more concerned for power than for people. That is why we need things like 15M, which,
    again, is not just “people meeting in the streets”. Because so far political
    parties have being thinking they can do whatever they want during the four
    years following each elections, actually the only “disrespectful” thing someone
    has done to all those millions of people that did voted them.


    We may follow
    this interesting conversation whenever you want.


    Best regards,