This chapter examines the financial and human resource commitments of the DHBC towards community action initiatives, highlighting the modest share of resources dedicated to this area. It explores the specific budget lines and the legal and regulatory challenges associated with funding community projects. Additionally, the chapter delves into the human resource aspects, underscoring the scarcity of staff officially dedicated to community action and the skills gap that exists among the current workforce.
Community Action to Strengthen Health Equity in the Spanish Basque Country
Abstract
Community action, despite its recognised importance for improving public health outcomes, currently represents a minor portion of the DHBC’s financial and human resource allocation.
4.1.1. The majority of DHBC’s budget funds Osakidetza, and the second biggest allocation is to pharmacy budget line
The budget of the DHBC is sizeable, although below the OECD’s average in terms of share of GDP. In 2022, the DHBC was allocated a budget of approximately EUR 4.3 billion, which is the largest allocation in the Basque Country’s budget, accounting for about 5% of its GDP, and the 1 per capita expenditures are the highest among all the AC in Spain (Ministerio de Sanidad, 2022[1]). The DHBC funds a wide range of activities related to the health and well-being of the Basque population.
The largest share of the budget (81% in 2022) was allocated to the financing and contracting budget line,2 which finance healthcare services (see Table 4.1). A significant part of this budget line (68%) was channelled to Osakidetza through the “Contrato-Programa Osakidetza y Ostek SA”. The remainder went to financing and contracting other providers. The last column of the table shows that more than 92% of the budget excluding the funding for Osakidetza is allocated to financing and contracting of other providers (about EUR 600 million) and to pharmacy (about EUR 530 million, mostly to pay medicines).
Note: The Public Health (4 113) and Addictions (4 116) budget lines are under the responsibility of the Directorate of Public Health and Addictions.
1. This budget line has one part under the responsibility of the Health Vice‑counsellor’s office (4112‑10), which is the one that includes the “Contrato-Programa Osakidetza” and another part under the responsibility of the Directorate for Social and Health Policies Integration (4112‑14), which includes the “Convenios de atención sociosanitaria”, which may include some community action component.
2. This amount does not represent the totality of the Osakidetza budget but is, from far, the most important. Several other contracts between the DHBC and Osakidetza exist for a total budget of EUR 3.5M in 2022.
3. The percentage assigned to Financing and Contracting is calculated excluding the EUR 2.972 M of the “Contrato-Programa Osakidetza”.
Source: Government of Basque Country (2022[2])
The second-largest budget allocation is directed to the pharmacy budget line, managed by the Directorate of Pharmacy, which accounts for nearly 12% of the total budget (see Table 4.1). While the majority of these funds (98%) are allocated to purchasing medication and related pharmacy services, a small portion supports community-oriented projects. For example, in 2022, EUR 120 000 was allocated to pharmaceutical socio-health initiatives, EUR 675 000 to the Matia Foundation3 – an organisation that supports individuals through the ageing process to improve their well-being – and EUR 80 000 to a pharmacotherapy monitoring project4 aimed, among other objectives, at increasing the healthcare contributions of community pharmacies.
The DPHA and the Directorate for Social and Health Policy Integration oversee the third and fourth largest budget allocations from the permanent budget lines. The public health budget lines account for almost EUR 51 million, while the addiction budget line is nearly EUR 5 million. This corresponds to 1.3% of the total budget and 4.6% of the budget excluding funds allocated to Osakidetza and temporary budget lines. The Directorate for Social and Health Policy Integration manages budget lines amounting to approximately EUR 35 million, which are part of the financing and contracting budget line. A significant portion of these budget lines is transferred to the provincial governments to support social programmes aimed at improving the health and well-being of their populations.
4.1.2. The DPHA has provided stable but small financing to community action over the past years
In absolute terms, the public health budget line provides a larger amount for community action than the addictions budget line. However, considered in relative terms, the amount dedicated to community action represents a small share of the public health budget line than for addictions. The expenditure structures of addictions (Panel A) and public health (Panel B) budget lines consist of four main categories: staff, operations, grants and transfers, and other.
In 2022, the majority of the public health budget lines was allocated to operations (46%), with staff costs representing 41%, and grants and transfers, which include community project funding, accounting for 12%. Conversely, the addictions budget line structure is different, with 70% allocated to grants and transfers, and only a significantly smaller proportion for staff and operational expenses. As a result, although the budget amount assigned to addictions was significantly smaller than for public health, it allocated a significant part of its funds to grants and transfers for organisations involved in community work (see Section 4.2.2 for details).
Share of the budget line, in 2022
Note: Staff only includes professionals working in central services. In the Public Health programme, the budget going to Staff includes both the Vice‑counsellor’s Office and the DPHA. The budget going to finance community projects comes Subventions & transfer expenditure line. Operations budget in the Public Health programme is mostly explained by vaccines purchase.
Source: Government of the Basque Country, (2022[2]), “General Budget of the Autonomous Community of the Basque Country “, https://www.euskadi.eus/contenidos/informacion/presupuestos_cae/es_def/adjuntos/pdfs/2022A/09_Osasuna_Salud.pdf.
In absolute terms, the budget for health promotion from public health and addictions budget lines has remained stable between 2017 and 2022. The total budget allocated to these budget lines is slightly over EUR 30 million (excluding staff expenses), Panel A of Figure 4.2 shows that between 2017 and 2022, while the public health budget line increased its funding by 34% (partly due to vaccine procurement and distribution after 2020), the addictions budget line remained relatively stable. Within these two budget lines, the amount allocated to health promotion is less than 10% of the total budget line (approximately EUR 1.2 million in 2022). As shown in Panel B of Figure 4.2, the budget specifically for health promotion projects within the public health budget line stood at EUR 841 000 in 2022. Despite a slight increase in absolute terms, the part of the budget allocated to promotion has seen a slow but steady decline since 2017 (from 3.2% to 2.8%). The budget for health promotion within the addictions budget line has remained relative stable since 2017 (approximately EUR 1.5 million in 2022).
In relative terms, the budget for community action accounts for a very small fraction of the addictions and public health budget lines and saw a reduction in 2022 after stability in previous years. Excluding staff expenses, the budget for community action is estimated at less than EUR 700 000 per year, representing less than 0.02% of the total DHBC budget.5
Many of these projects require minimal budget beyond salaries of those who manage them. However, despite the low funding, community action projects can have a strong positive impact on the health outcomes of the communities. The financial resources allocated to health promotion are not fully synonymous with community action. According to the DHBC estimates,6 in 2022, 45% of public health budget line was allocated support community action, down from 56% in 2017. The budget remained stable from 2017 to 2021 but experienced an 11% cut in 2022. Conversely, the addictions budget line, which lacks a dedicated funding for community action, allocated 15%‑22% of its funding to community projects, increasing from about EUR 275 000 in 2017 to EUR 343 000 in 2021, before a 34% reduction brough it down to EUR 226 000 in 2022.
In millions of EUR
Note: Number in parenthesis in the legend refer to specific budget lines as they appear in the Basque budget. The budget does not include costs of staff. There is a discrepancy between the published budget of the DHBC and data sent by the DHBC.
Source: Questionnaire filled out by the DHBC.
Trends in average funding per project and the overall number of projects have evolved in opposite directions between public health and addictions budget lines. Figure 4.3 illustrates the number of projects and the average funding per project between 2017 and 2022.7 Each panel refers to projects financed by different grants:
None of the grants financed by the addictions budget line are fully dedicated to community action (see Chapter 3, Table 3.2). However, many projects receiving either the “Development of community prevention programmes for addictions and the promotion of healthy behaviours” grant or the “Prevention and reduction of risks and damages and the promotion of healthy behaviours” grant have a strong community component. In 2022, these two grants had a combined budget of EUR 1.7 million, supporting a total of 127 projects. More than half of these projects involved community activities. They received, on average, EUR 3 145 per project, nearly four times less than the overall average funding per project. The addictions budget line has increased the number of supported community action projects while decreasing the average funding per project (see Panel A of Figure 4.3).
The health promotion component of the public health budget line primarily funds two grants for community action. The “Development of Actions Aimed at Promoting Physical Activity among Students” grant was allocated EUR 136 000 in 2022. Between 2017 and 2022, the number of supported projects fluctuated between 30 (2017) and 21 (2020). The trend shows an increase in the average funding per project from EUR 3 133 in 2017 to EUR 4 533 reflecting a shift towards funding fewer projects with higher individual budgets (Panel B).
The second grant financed from the public health budget line, “Development of Local Health Promotion Programmes” grant, had a steady budget of EUR 292 000 from 2017-2020 but faced cuts in 2021, reducing it to EUR 250 000. The number of projects funded annually varied significantly, with a decline from 116 projects in 2017 to 40 projects in 2022. Since the total budget was relatively stable during this period, the average project funding increased by about 150% from EUR 2 517 in 2017 to EUR 6 250 in 2022 (Panel C).
Note: Average amounts in EUR. Public – Health – Municipalities refers to the projects financed via Development of Local Health Promotion Programmes grant. Public Health – Schools refers to the projects financed via Development of Actions Aimed at Promoting Physical Activity among Students grant. Addictions refers to the project financed from Addictions programmes and marked as supporting community action in health by the DHBC.
Source: Questionnaire filled out by the DHBC.
In addition to the four previously described grants, the addictions and public health budget lines allocate funding to three additional grants that can support community action projects. Two of these grants (the bottom of Chapter 3, Table 3.1), funded from the public health budget line, had budgets of EUR 300 000 each with a budget of EUR 300 000. Another grant, belonging to the addictions budget line (the bottom of Chapter 3, Table 3.2), provided funding for professionals working in municipalities who are responsible for, among other things, organizing addiction-related community action. In 2022, this grant helped to co-finance posts in 36 municipalities, providing an average of EUR 32 614 per municipality. This funding level typically allows for the employment of one professional per municipality to carry out these tasks.
4.1.3. The mechanisms for financing community action by the DHBC encounter some legal and regulatory challenges
There are recurring legal concerns whether grants financed by the DPHA to municipalities (see Chapter 3, Table 3.1 and Table 3.2) might constitute an encroachment on local competences and should be discontinued. Lack of clarity with respect to the division of competences by each level of government or their interpretation is at the heart of this discussion. On the one hand, according to the Article 17 of the Law 2/2016, of Local Institutions in Euskadi, the promotion, management and protection of public health is a municipal responsibility.8 From this perspective, a cash transfer from the DHBC might be seen as influencing priorities that municipalities should finance with their own funds. On the other hand, Law 13/2023, of Public Health in Euskadi, establishes the Basque Public Health System with the mission of exercising strategic leadership in population health, promoting its protection and promotion in cross-sectoral policies (Art. 6‑g) and enhancing health and well-being through interventions aimed at increasing knowledge, skills, and changing social conditions (Art. 6‑i). Therefore, the DHBC’s provision of grants to support community action for health, is in principle aligned with its legally established mission.
There is a need to find more structural solutions to avoid uncertainty and administrative costs. So far, this legal challenge has not prevented the DHBC from funding projects that meet the grant criteria. However, DHBC’s legal advisors have to analyse and justify the terms and conditions of each call for tenders. This funding is crucial for municipalities, especially small ones, as it enables them to initiate and sustain various projects and retain experienced professionals. Several solutions could be examined:
Clarify the legal division of competences regarding the promotion of community health. This should involve the Commission of Local Governments which, so far, has not expressed a firm position on this matter. It would be interesting to analyse the possibility that the DHBC provides this funding through the Basque Municipalities Association and if this alternative avoids a legal challenge.
Align the budget and the competences. If operational actions to promote community health are deemed municipal responsibilities (and hence the DHBC should not provide cash transfers for them), then their budget should be adjusted accordingly, with municipalities being accountable for outcomes in this area.
Change the terms of the public call for the projects. To streamline the process and reduce the need for regular and tedious revisions and justifications, it is recommended to modify the terms of public calls for community projects. This adjustment should be informed by the analyses that have supported the acceptance of DHBC funding in recent years.
Explore other instruments to support community projects. The agreements system (convenios), often used in the socio-health area, might be an interesting alternative as it is more flexible and does not raise the issue of stepping into the competences of municipalities. Involving the future Basque Institute of Public Health, which has a clear mandate to support community action based on the new law of Public Health in the Basque Country (see Chapter 2, Section 2.2.3) could also be a tool to co‑ordinate and support community action for health at all levels.9
The previous section shows that the budget allocated to finance community action projects constitutes a very small share of the DHBC budget. This section analyses the role and work of the DHBC in community action from the human resources point of view.
4.2.1. Few staff within DHBC are officially allocated to work on community action in contrast to Osakitdetza
A large share of DPHA staff works in health protection or in laboratories. In 2022, the DPHA employed an estimated 338 people,10 including the central services, laboratory professionals, the three sub-directorates based in Vitoria-Gasteiz, Donostia-San Sebastián and Bilbao, as well as personnel in the nine district offices (see Table 4.2). These professionals fulfil various roles: 58 of them (15% of the total) are managers or administrative staff, 66 (20%) work in the analysis laboratories, slightly more than 20 (6%) are in the Health Promotion and Addictions units, 163 (48%) work in the Health Protection unit (including slaughterhouse veterinarians), and 30 (9%) fulfil monitoring tasks.
Staff time dedicated to community action constitutes a small fraction of the total. The Health Promotion unit, while focussed on community action, dedicates approximately 35% of their time to it. In full-time equivalent terms, this corresponds to approximately five persons, representing less than 2% of the total DPHA workforce. Most of these professionals are based in central services or sub-directorates in provincial capitals, which limits their direct engagement with communities in the health districts. The unit focusses on developing a strategy to promote community action for health, allocating funding, co‑ordinating projects and, whenever possible, the providing of technical support to stakeholders working in the field.
Note: Staff working the Health Promotion unit often focus on community action. In exceptional situations, staff from other units can also be involved in these programmes. However, and depending on the nature of projects, Addictions and Health Protection staff might be involved in projects with the community.
1. In each District Centre (see Chapter 3, Box 3.1) there is a co‑ordinator who has been included in the column “Protection”.
2. All veterinarians work in slaughterhouses except for two, in the Interior district, that should be considered as working in Protection.
Source: Questionnaire filled out by the DHBC.
The lack of staff allocated to community action in health districts hinders direct engagement with communities and the expansion of community activities. As discussed in Chapter 3, Section 3.2, staff in health districts is working mostly on health protection as their mandate is to focus on health protection. At the same time, the OECD mapping survey undertaken to document currently ongoing community action initiatives as well as information gathered during the fact-finding mission revealed that many DPHA employees at the district level engage in community action. The OECD mapping survey estimates that at least 32%11 of all district-level employees are engaged in community action initiatives (see Chapter 6, Sections 6.1 and 6.2 for more details).
Additionally, some district staff engage in community action on their own initiative, often alongside their primary health protection duties. This engagement is typically not officially recognised by the senior management.12 The OECD mapping survey further shows that about 45% of DPHA staff at the comarca level who replied to the survey work on community action during their free time (see Chapter 6, Sections 6.1 and 6.2). An explicit mandate for community action, accompanied by sufficient time allocation, would facilitate greater community action and project implementation. This could be achieved by adjusting existing responsibilities or recruiting additional staff to support these initiatives.
Osakidetza’s decision to hire community nurses indicates a significant commitment to community action in terms of absolute staff numbers. While it does not fund community action projects directly, Osakidetza’s Sub-directorate of Primary Care has allocated human resources to serve as a bridge between public health services and the organisers of activities to improve community health. These professional, known as “community nurses”, are attached to the OSIs. In 2022, there were 37 community nurses. On average, each nurse is responsible for a population of over 61 000 people, with significant variations across different geographical zones (see Table 4.3). Moreover, every primary care unit appoints a person responsible for community activities. Yet, their commitment to community work is only-part time and their primary role can differ across primary care units. While the proportion of Osakidetza’s staff dedicated to community action is relatively low (less than 0.02% of its total workforce of over 30 000), the absolute number of staff involved is significantly higher than in the DHBC. This indicates that Osakidetza is likely to play a pivotal role in directly engaging with communities and co‑ordinating community health initiatives.
By OSI, data from 2022
Note: The geographic distribution of districts used by Osakidetza (Organización Sanitaria Integrada, OSI) does not coincide with Department of Health’s districts (see Chapter 3, Box 3.1).
Source: Osakidetza, (2023[3]), “Estrategia para el abordaje de la salud desde una perspectiva comunitaria en Atención Primaria”, https://www.osakidetza.euskadi.eus/contenidos/informacion/osk_trbg_planes_programas/es_def/adjuntos/Estrategia-abordaje-salud-C-_2025.pdf.
4.2.2. The DHBC is consolidating staff contracts and may need to reevaluate future hiring profiles to enhance community action initiatives
To establish robust links with communities and better understand their needs, it is essential to minimise staff turnover within the DPHA. The DPHA aims to reduce the number of staff on temporary contracts, which should decrease turnover and facilitate long-term community action. Currently, the DHBC employs part of its staff on temporary contracts.13 This situation is not unique to health workers but also exists in other public administration areas. To address it, the Basque administration has initiated a selective process for consolidating temporary employment. The aim is to transition individuals who have been working on temporary contracts, sometimes for several years, into permanent civil servant positions.14 Interested temporal stuff must apply for a job consolidation tender and undergo a selection process. The selection is based on a scoring system that assigns points for educational background, language skills (Basque language is mandatory for some positions), previous work experience, in particular in similar positions, and additional tests. Box 4.1 presents two examples of the employment consolidation process in the DHBC.
In terms of employment policy, the Basque public administration adheres to strict rules derived from the European Union directives, as well as Spanish and Basque legislation. Access to civil servant positions in the public administration is conducted through a selection process known as the “opposition system” (sistema de oposiciones).15 An “opposition” is an examination based on the principles of equality, capacity and transparency. Generally, the process involves one or more tests aimed at assessing candidate’s ability to perform the functions of the position. To succeed, candidates need to be thoroughly familiar with each phase of the process and prepare well in advance, as it is highly competitive. Additionally, in recent years, the administration has emphasised principles of equal opportunities, respect for minorities and diversities, balanced representation and gender perspective, as well as the linguistic standardisation of Basque language.16
While this system ensures transparency and the recruitment of well-qualified staff, it has faced criticism for being somewhat outdated and mainly knowledge‑based. It does not place sufficient importance on other skills, or adequately consider candidates’ professional experience.17 A significant drawback is that positions are not classified according to the specific functions required, nor are they attached to specific knowledge requirements in public health matters. Additionally, the newly develop additional principles for equity makes the recruitment process slower and more cumbersome.
Laboratory Assistants
Applicants were required to hold a Senior Laboratory Technician in Analysis and Quality Control Laboratory diploma or equivalent, to hold European citizenship, and other, relatively standard, requirements such as experience, physical and mental condition compatible with the functions, etc. For this position the specific professional experience as laboratory assistant for the Basque administration was assessed at the rate of 0.170 points per month worked in the last 25 years up to a maximum of 45 points. This rule recognises the work done by internal candidates, especially those who have been working for the Basque administration for many years. For example, someone who has worked as laboratory technician for the DHBC for five years would increase their score by (5*12)*0.170=10.2 points, which is a significant plus given the fact that the maximum score for this position was 100 points.
Corps of Technical Assistants. Health and Environment Laboratory and Inspection Scale
In addition to the standard requirements, applicants were required to hold any of the following diplomas: Higher Technician in Industrial Chemistry, Higher Technician in Analysis and Quality Control Laboratory, Higher Technician in Clinical and Biomedical Laboratory or Higher Technician in Chemistry and Environmental Health. In this case, several different jobs were eligible to credit specific experience, assessed at a rate of 0.277 points per month worked up to a maximum of 40 points. Again, someone with five years of a specific experience would have increased his/her score of 0.277*60=16.6 points (out of a maximum total score of 120 points).
Source: More details about the position of Laboratory Assistants available at: https://www.euskadi.eus/empleo_publico/ayudante-de-laboratorio-proceso-excepcional-de-consolidacion-de-empleo-concurso/web01-sedeopec/es/. More details about the positions of Corps of Technical Assistants, Health and Environment Laboratory and Inspection Scale available at: https://www.euskadi.eus/procesos-selectivos-de-consolidacion-de-empleo-temporal-informacion-general/web01-sedeopem/es/
The profiles hired within the DPHA are limited and not focussed on competencies that facilitate community action. Despite the increasing emphasises on a community approach in public health, the recruitment process at DHBC is predominantly geared towards health protection roles. Current vacancies for health promotion positions are often designated for public health technicians and epidemiologists. There are no guidelines for recruiting candidates with specialised education and training in community action or experience and training as a social worker. This gap highlights a need for a more diversified recruitment strategy to include professionals skilled in community action.
Osakidetza operates an independent recruitment system. In 2019, Osakidetza introduced a new a new model for staff selection (Department of Health - Osakidetza, 2019[4]). This model addresses strategic challenges related to generational changes and the demand for new professional profiles. The new approach composed of three steps:
Stabilisation of current staff: As of 2018, many Osakidetza employees worked on interim or fixed-term contracts. The consolidation of employment, similar to the DHBC process, began in 2016 to provide more stable employment conditions.18
Renewal of personnel: With a significant portion of the workforce nearing retirement, there is a need for generational replacement. This step focusses on adequately covering posts that will become vacant in the coming years.
Redefinition of professional profiles: Adapting to scientific and technological advances (like genetics, robotisation, 3D, biotechnology, etc.), new work dynamics from digitalisation, redesigning public health services, (like adoption of a community approach in public health), and the demographic challenge is essential for future recruitment.
Both the DHBC and Osakidetza make efforts to improve the contractual situation of their current staff. Osakidetza is also focussed on renewing professional profiles to meet current and future public health challenges. This process follows a well-designed recruitment strategy and is being implemented gradually. However, the DHBC’s recruitment policy does not seem to have a similar strategic approach. By recruiting suitable professionals under stable contractual conditions, DHBC has an opportunity to enhance its work in community action for health.
4.2.3. Access to formal education and training in community action has expanded in recent years
Specific efforts have been undertaken to provide training in community action. The lack of training among professional was acknowledged in the DPHA’s “Methodologic guide to address health from a community perspective” (Dirección de Salud Pública, Gobierno Vasco, 2016[5]). In 2015, Osakidetza organised two courses to address this training gap. An introductory course on the community approach to health was included in the training itinerary for primary care professionals. Additionally, Osakidetza offered an advanced course for 54 Osakidetza and DHBC professionals. These trainings led to the reinforcement or initiation of 38 community work processes across all OSIs and district units of DPHA. Following this, in 2015/16, Osakidetza launched an online training course aimed at raising awareness about community action among health professionals, focussing on the benefits of community participation and identifying health community assets.
In recent years, the academic background and professional profiles of those working in community action for health in the public sector have become more distinctly defined. Consequently, the offer of academic trainings on community health has been consolidated and adjusted to new needs. For instance, as of 2024, the University of the Basque Country19 offers comprehensive training in health promotion and community health, including:
University specialisation in Health Promotion and Community Health: This programme aims to equip students with basic skills for work in health promotion and community health. It adopts a biopsychosocial approach to health and cover elements such as social determinants of health, health promotion, and the positive vision of health, both conceptually and practically.
Masters in Health Promotion and Community Health: Building upon the university specialisation described in the previous bullet point, this lifelong learning programme explores various approaches to community health, from action in communities, to the promotion of healthy environments and policies, and improving health behaviours. It also provides essential skills for designing, developing, and evaluating interventions in health promotion and community health.
In the coming years, the development of professional profiles specialised in community health should be reflected in the hiring requirement for specific positions (e.g. community nurses or technicians in community health). The future Basque Institute of Public Health could play an important role in co‑ordinating this process and ensuring the overall coherence of the academic curricula and the training of the many professionals within the health system. In fact, the Law 13/2023 indicated, as one of the objectives of the Basque Institute of Public Health to “… promote and encourage, in collaboration with the responsible bodies, universities and research centres, the training of professionals and research in public health.”
References
[4] Department of Health - Osakidetza (2019), Osakidetza, Nuevo modelo de procesos de selección, https://www.euskadi.eus/contenidos/informacion/nuevo_modelo_ope/es_def/adjuntos/nuevo-modelo-ope.pdf.
[5] Dirección de Salud Pública, Gobierno Vasco (2016), Guia metodológica para el abordaje de la salud desde una perspectiva comunitaria, https://www.osakidetza.euskadi.eus/contenidos/informacion/publicaciones_informes_estudio/es_pub/adjuntos/guia-metodologia-esp.pdf.
[2] Government of Basque Country (2022), “General Budget of the Autonomous Community of the Basque Country”, Chapter 9 (Health), https://www.euskadi.eus/contenidos/informacion/presupuestos_cae/es_def/adjuntos/pdfs/2022A/09_Osasuna_Salud.pdf.
[1] Ministerio de Sanidad (2022), Estadística de Gasto Sanitario Público, https://www.sanidad.gob.es/estadEstudios/estadisticas/docs/EGSP2008/egspPrincipalesResultados.pdf (accessed on 17 July 2024).
[3] Osakidetza (2023), Estrategia para el abordaje de la salud desde una perspectiva comunitaria en Atención Primaria, https://www.osakidetza.euskadi.eus/contenidos/informacion/osk_trbg_planes_programas/es_def/adjuntos/Estrategia-abordaje-salud-C-_2025.pdf.
← 1. Throughout this section, references are made to fiscal year 2022, unless stated otherwise.
← 2. The term budget lines employed in this chapter correspond to what is called “programas” (broken-down in various items or “partidas presupuestarias”) in the Basque budget. They do not fully overlap with the organisational structure presented in Chapter 3.
← 3. To learn more about the foundation, check here: https://www.matiafundazioa.eus/es.
← 4. To learn more about the project, check here: https://www.pharmcareesp.com/index.php/PharmaCARE/article/view/685.
← 5. It is difficult to clearly determine the perimeter of community action projects. Figures presented here correspond to what the DHBC considers as community action projects. Some funding coming from the Health Protection unit of the DPHA, and to a lesser extent from the socio-health, and pharmacy programmes, might be added and will increase the amount to some extent.
← 6. Estimates based on the questionnaire filled out by the DHBC. Applies to all numbers in the remaining part of the Section 4.1.
← 7. As explained in Section 3.2, the cash support provided by the DPHA to community action projects is organised in several thematic grants. Each grant has an overall maximum budget that is used to fund different projects. The figure only includes those projects considered as community action by the DHBC.
← 8. Though, the expression “exclusive competence” is not used in the Law 2/2016.
← 9. The agreement system is one of the formulas available to public administrations to organise the provision of services, either through direct management or through indirect management within the framework of public administration contracting regulations and agreements with non-profit organisations. See for example, the Decree 168/2023 of 7 November, in the area of social services.
← 10. Not all of them work full time. Therefore, figures in this section are expressed on a full-time equivalent basis.
← 11. This number is computed as the number of reported staff working on community action by survey respondents who replied to work at a district office of the DPHA as a share of the total staff of the DPHA working at the district level.
← 12. This can even lead to paradoxical situations where Health Protection unit personnel that are key for the survival of an activity involving the community (and often highly appreciated by it) are, from a strictly institutional point of view, acting completely out of their mandate and somehow in contradiction with it (mainly focussed on control, supervision and auditing).
← 13. During the fact-finding mission, this situation appeared as quite frequent, especially among people working at local level, both in the DHBC and in Osakidetza (DPHA technicians, nurses and other).
← 14. For more information check https://www.euskadi.eus/procesos-selectivos-de‑consolidacion-de‑empleo-temporal-informacion-general/web01‑sedeopem/es/.
← 15. For a concrete example taken from Osakidetza check: https://www.opositor.com/landing/osakidetza?piloto=V82&.
← 16. A good example of these rules and principles can found here: https://www.euskadi.eus/contenidos/empleo_publico/.
← 17. An example the type of criticism to the oppositions system has received in past years can be found here: https://www.industrialesoposicion.es/2018/07/oposiciones-ventajas-e‑inconvenientes-analisis.html.
← 18. To this process belong the OPE (tenders) launched in 2016‑2017 and 2018‑2019.
← 19. The University of Vitoria-Gasteiz also proposes online training called “Expert in health promotion and community health”.