Community Action to Strengthen Health Equity in the Spanish Basque Country

2. The institutional setup for community health in the Basque Country is intricate

Abstract

This chapter examines the institutional set-up supporting community health in Spain and the Basque Country, with particular attention to recent legislative developments and their implications for facilitating community-led health initiatives. It shows how the regulatory framework has been assigning more importance to community health action.

Introduction

The institutional framework plays a key role in enabling community action for health. A well-designed and accessible system can empower communities to take an active role in improving health and well-being. In contrast, complex, opaque, and fragmented institutional arrangements can discourage even the most committed communities from launching initiatives.

2.1. The division of competences in the area of health is complex in Spain

2.1.1. In Spain, health competences are shared across levels of government

Spain is a highly decentralised country, and many public services are provided at the regional level. According to the 1978 Constitution, Spain has a three‑tier system with central, regional, and local governments. There are 17 self-governing Autonomous Communities (AC), 2 autonomous cities, 50 provinces, and 8 131 municipalities. The division of competences across different government levels is regulated by the Spanish Constitution. While some public services are exclusively provided by the central government, most, including health, are jointly managed by the central and regional governments. In contrast, certain public services, like social services, are exclusively managed at the regional and municipal levels (OECD, 2022[1]). As a general rule, all responsibilities not expressly attributed to the central government by the Constitution can be devolved to AC or regions. Additionally, the Statute of Autonomy for the Autonomous Community of the Basque Country provides a detailed list of areas where the Basque Country has exclusive competences. The 1985 Law Regulating the Local Administration further clarifies some of the competences of local authorities and establishes the possibility for competences to be devolved to the local level. Spain also has other bodies at the province or island level (diputaciones, cabildos and consejos insulares), or joining several municipalities (mancomunidades), which might be relevant for community action initiatives organised in municipalities with a low number of inhabitants or in remote territories.

The division of competences in health matters across various levels of government is complex in Spain. The co‑ordination of health policies between national and regional levels is organised through a permanent body: the Interterritorial Council of the National Health System (CISNS, by its acronym in Spanish). The Article 149.16 of the Spanish Constitution specifies that the central government has exclusive competences over external health, the basic rules governing the health systems (i.e. minimum floors and requisites for equal rights across the territory), healthcare co‑ordination, and the regulation of pharmaceutical products, while Article 148.21 states that the AC are responsible for public health and hygiene. The General Health Law 14/1986, 25 April (Ley General de Sanidad or LGS) regulates the structure of the health system and further specifies the division of competences. Following this, the central government also holds competences related to inter-regional solidarity and high inspection. In turn, the AC are responsible for implementing and managing the health system and policies. They can also develop legislation and norms with respect to health according to the specific competences detailed in each of Autonomy Statutes. In this context, the CISNS’s mission it to guarantee the co‑ordination, co‑operation, communication and information between the regional and the national health authorities. As a body for co‑operation between the State and the AC, the CISNS is also entrusted with promoting the cohesion of the National Health System. The Spanish Minister of Health chairs the Interterritorial Council and each Autonomous Community’s Health Minister (or Health Counsellor) is represented in the Council.

2.1.2. In the Basque Country, the division of health competences is similarly complex

Within the Basque Government, the DHBC is the health authority of the Basque Country, responsible for providing the stewardship, planning, organisation, administration, and evaluation of health plans and programmes, as well as providing oversight and directing to the provision of health services, including those in the public health domain and healthcare. As part of this effort, Law 10/1983 established the Basque public healthcare service, Osakidetza. This structure has evolved over time to include the provision of all curative healthcare services to the resident population in the Basque Country. It includes a network of primary healthcare centres, secondary and tertiary hospital and specialised healthcare services, diagnostic and laboratory capacities, emergency care services, a mental health network, and ancillary services. Over 40.000 professionals from a wide range of disciplines are currently engaged in Osakidetza. In 1997 (through the Law 8/1997, the Basque Health Organisation Act), Osakidetza was transformed into an autonomous administrative body, attached to the Department of Health and Social Security (currently DHBC) of the Basque Country. Under its direction, supervision and guardianship Osakidetza carries out its attributed functions. The DHBC specifies Osakidetza’s priorities, approves its budget and oversees its functions, which are primarily concentrated on the provision of healthcare to all residents of the Basque Country.

The Law 8/1997, the Basque Health Organisation Act (Ley de Ordenación Sanitaria de Euskadi orLOSE) abrogated the Law 10/1983 and reorganised the Basque health system. It defined the geographical organisation of the health system and provided a clearer, developed definition of the competences and organisation of Osakidetza, changing its legal nature. The law replaced the old autonomous body with a public body governed by private law and guaranteed its continuity and name (Basque Health Service‑Osakidetza). The law also defined health prevention and health promotion concepts and regulated the intervention of local administrations. However, the organisation has evolved significantly since 1997 and many initiatives included in LOSE have been overruled long time ago.

Within the DHBC, the DPHA is the entity responsible for the provision of public health functions. These include health protection, health promotion, epidemiological surveillance, population-based health status monitoring, diseases and injuries prevention, and preparedness and response to health emergencies, as well as public health co‑ordination and oversight. The DPHA has focussed on fostering community action through various programmes as an essential vehicle to conveying health promotion programmes and activities.

Several provisions impact the organisation of community action for health. The competences for action in areas other than health (urban planning, social services, environment, etc.) in the territory and which are related to addressing the social determinants of health lie primarily with the provincial governments and secondarily with the municipalities The Provincial Government Law (Régimen Foral) of the Basque Country gives fiscal autonomy to its three provinces of Araba, Bizkaia and Gipuzkoa. Each province may therefore deploy different arrangements to deliver its competences. Importantly, each province has the competence to maintain, establish and regulate their tax systems, including the ability to collect, manage and inspect all state taxes – that is, all the taxes established by the central government – except for import duties and the value added tax. Specialised social services are under the competence of provinces, while local governments have competences over the provision of primary social services and over the organisation citizen participation processes, including community action projects. While these competences in the area of social services, they have an impact the way social determinants of health are addressed. In fact, community action interventions organised by health and social services sometimes overlap and, in such cases, there is no clear definition about who has the leadership.

Public authorities are not the only actors in the service provision. Private profit and non-profit organisations play a crucial role in the implementation of concrete programmes and activities in social action, significantly impacting the social determinants of health. The Basque Country regulates the activities of these private actors through two texts: Law 6/2016 regulates the Third Sector of Social Action, and Decree 168/2023 regulates the social agreement system (Régimen de concierto social) and the partnerships in the Basque Social Services System (convenios en el Sistema Vasco de Servicios Sociales). The social agreements system is one formula available to public administration to organise social services provision included in the Catalogue of Benefits and Services of the Basque Social Services System. Law 6/2016 also establishes a strong link between third sector organisations and the Basque Social Services System.

2.2. The regulatory framework has assigned more importance to community health over time

2.2.1. National legislation points to the importance of community action for health

Over the past 20 years, the legal and regulatory framework in Spain has been developing the concept of community action in health as well as the interventions to support its implementation. A number of national laws related to public health and the national health system provide guiding principles on community health.

The first of these is the 1986 General Health Law, which mentions the active participation of community members in improving the health conditions of their community. Although, this law does not specifically use the term “community action” in health (see Chapter 3), Articles 5 and 6 establish that the Public Health Services shall be organised to facilitate community action through the corresponding territorial corporations in the formulation and control of health policy. Additionally, the actions of Public Health Administrations should promote individual, family, and social interest through adequate health literacy.

Secondly, Law 16/2003 on the Cohesion and Quality of the National Health System clearly establishes in Article 12 that primary care is the basic and initial level of care guaranteeing comprehensive and continuous care throughout the patient’s life. This includes activities in prevention, health promotion, family care, and community care. Article 11 defines public health provisions as a combination of sciences, skills and attitudes aimed at maintaining and improving the health of all people through collective or social actions. Thus, this law assigns a primary role to the users of the health system in maintaining or improving community health collectively. Article 67 also defines the means through which users can participate in the national health system: the Consultative Committee (under the CISNS), the Open Health Forum, and the Virtual Forum, creating a space for all citizens to voice their opinions on health policy issues.1

Thirdly, Law 33/2011 on General Law on Public Health indicates in its preamble that health services, especially primary healthcare, should assume a more significant role in community health through preventive actions. Article 23 advocates for effective collaboration between public health and healthcare, while Article 26 establishes that public health services should adopt measures to make health centres “health promotion centres” following WHO guidelines, developing a health promotion plan in co‑ordination with the competent public health authority of the autonomous community or city. Article 31established the need for a Public Health Strategy to ensure that health and health equity are considered in all public policies and to facilitate intersectoral action.

Beyond legislation, other important developments emphasised reducing health inequalities and the importance of community action. In 2008, the Commission to Reduce Social Inequalities in Health in Spain was set up. This commission identified the factors to address to reduce health inequalities. These factors include the distribution of power, wealth, and resources, living and employment conditions, health-promoting environments, and health services. Determinants of health include individual resources such as people’s skills and capabilities, community networks, participation in these networks and the social support received. The Public Health Strategy 2022 of the Ministry of Health introduces the term community health in several public health monitoring indicators. The strategy also indicates that community health should be promoted through advocacy, training, intersectoral work and participation. This efforts should be co‑ordinated with the AC, local authorities, and associations, such as the Community Health Alliance, and through the production of reference documents like “Community action to gain health” (Ministerio de Sanidad de Espana, 2021[2]) and “Participate to gain health” (Ministerio de Sanidad de España, 2019[3]).

Over the past decades, Spain has progressively emphasised the role of public health in providing health services and explicitly included the idea of community action as part of it. In 2013, the Health Ministry published a Strategy for Health Promotion (Estrategia de promoción de la salud y prevención en el SNS) which includes health empowerment and participation and community action as one of its strategic directions. In November 2018, the plenary session of the CISNS agreed with the AC to develop a Strategic Framework for Primary and Community Care (MAPyC).2 This framework was designed and approved in April 2019 through a participatory reflection process with the AC, scientific societies, professional associations, patient associations and citizens. The MAPyC defined six strategic lines to strengthen various aspects of primary care, with Strategy D explicitly mentioning community action in health, associating it with health promotion and disease prevention in primary care. Although, implementation was delayed by the COVID‑19 pandemic, a Primary and Community Care Action Plan (PAAPyC) was developed in 2021 to strengthen the post COVID‑19 recovery of primary and community care in the National Health System. Concrete actions include:

• The creation of the professional category of specialist nurses in Family and Community Nursing in primary care in all the AC, promoting the appointment of nurses with this speciality.

• The development of Community Health Strategies for primary care in all AC.

• The mandate to generate and facilitate structures and co‑ordination mechanisms for community health, promotion and prevention between primary care, public health and other sectors and agents at different territorial levels: region, municipality, and neighbourhood.

In the guide Community action to gain health (Ministerio de Sanidad de Espana, 2021[2]), the Spanish Ministry of Health defines community action as the dynamisation of co‑operative social relations among people in a given area, with three transformative functions: (i) improving the living conditions, (ii) strengthening social cohesion and inclusion of excluded, and (iii) enhancing capacities for individual and collective action to improve health and well-being. This approach highlights the need to intervene in various domains impacting community health status, such as social as social services, community life, education and urban planning. This complexity makes it challenging to clearly determine the necessary intersectoral and collaborative processes, their design, management and sustainability, and the level of government responsible for a given initiative. Compared to the definitions of community action used at the international level (see Chapter 1, Section 1.1), the definition the Spanish Ministry of Health’s definition focusses on community health outcomes. In contrast, international definitions focus more on the implementation aspects of community action (albeit in abstract terms), while remaining imprecise about potential outcomes.

2.2.2. The Basque Country has adopted an approach to community action inspired by international definitions

In line with a global trend, the Basque Government has increasingly emphasised community health and the active participation of the community in health-related actions. The concept of community action was already mentioned in the Health Plan 2013-2020, which proposed “…to develop and boost community action in health through actions in the field of public health, with the participation and involvement of all stakeholders” (Departamento de Salud, Gobierno Vasco, 2013[4]). Since then, the DHBC and Osakidetza developed an integrated health plan for the institutions within the Basque health system aimed at adopting a proactive approach to public health based on three pillars: integrated governance, population focus, and community approach to health. This direction is confirmed and enhanced by the Health Plan Euskadi 2030, which specifies objective 6.5 to “promote social environments for citizen participation and community action in health at the local level, taking into account the diversity of populations and with a focus on equity” (Departamento de Salud, Gobierno Vasco, 2023[5]).

In 2015 the DHBC, in collaboration with Osakidetza, developed a conceptual framework to provide concrete tools for the Health Plan implementation. One of the tools, the DHPA designed in 2016 the guide Methodologic guide to address health from a community perspective, an important conceptual milestone. The guide includes a glossary defining the key terms related to community action, such as “health actives”, “community”, “community approach based in health actives”, and “health promotion” (Dirección de Salud Pública, Gobierno Vasco, 2016[6]). The definition of community action in health is as follows:

“Involving a community in the analysis, design, implementation and evaluation of community processes that meet their needs, set common goals and act cooperatively. It involves community organisation and collective awareness. Participation and community empowerment are closely related concepts.”

While this definition closely follows the WHO definition (see Chapter 1, Section 1.1), it makes a crucial distinction by defining a community as a group of people living and/or working in a defined geographical area. The WHO definition is more open, specifying that a community does not necessarily need to reside in the same geographical area.

The Methodologic guide to address health from a community perspective incorporates many elements from the WHO framework, but also from researchers working in this field in Spain (Marchioni, 2013[7]; Hernán, 2013[8]), and from the project Asturias Actúa3 conducted by the Health Observatory of Asturias. Although the guide remains somehow abstract, it includes a step-by-step methodology for community members eager to engage in health-promoting actions and introduces a comprehensive five‑stage approach to foster local health networks, assess and prioritise needs, and evaluate community health projects effectively.

In 2020, the DPHA and the Department of Governance of the Basque Country, in collaboration with iLab (Espacio de Innovación en Participación de Euskadi) and several other municipalities and institutions, published a second guide, titled Guide for Participation Generating Well-being and Health (iLab, 2020[9]). This guide builds on two main sources: the NICE report Community engagement: Improving health and well-being and reducing inequalities in health (NICE, 2016[10]) and its adaptation to the Spanish context published in 2018 (Cassetti V, 2018[11]). The Guide for Participation Generating Well-being and Health acknowledges that, although public administrations usually lead participatory processes, increasingly more initiatives are emerging from the communities. On this basis, the guide presents a set of evidence‑based guidelines and recommendations for all actors involved in participatory processes, regardless of their nature or objective. These guidelines follow three fundamental principles: (i) guarantee diversity in the constitution of decision making groups; (ii) promote the autonomy and self-management capacity of communities; and (iii) foster empathetic and trusting relationships between different stakeholders. Rather than providing a definition of concepts like community or community action, the Guide for Participation Generating Well-being and Health is practically oriented for those wanting to set up projects and focusses on the conditions needed to implement successful participatory processes.

2.2.3. The 2023 law on Public Health of the Basque Country clearly adopts a community approach to public health

The Basque Parliament approved Law 13/2023 of Public Health of the Basque Country (Salud Pública de Euskadi), which adopts a public health approach based on social determinants of health from a community and multi-disciplinary perspective, incorporating health into all policies. This law creates the Basque Public Health System, which co‑ordinates with the Basque Health System4 to provide a network of benefits, services, equipment, and management and co‑ordination tools aimed at preventing illness, injury, and disability, while protecting and promoting people’s health. Additionally, Law 13/2023 lays the foundations for the prevention, early detection, monitoring and effective management of health emergencies, epidemics and pandemics. It also establishes the Basque Institute of Public Health to provide public health actions, benefits and services.

Law 13/2023 is organised around four broad themes:

• Citizens and public health. The law outlines the rights and responsibilities of citizens in relation to health, emphasising dignity, equality, access to information and protection of private information, effective community participation and health education. It also details the tools and procedures available for citizens to participate in public health matters, including the planning, development, monitoring and evaluation of public health plans, interventions and programmes.

• Acting on health determinants and health in all policies. The law mandates that all public health actors should adopt the principle of “health in all policies” and address health determinants in a comprehensive, intersectoral and sustainable manner.

• The public health system in the Basque Country and its organisation. The law clarifies the roles and responsibilities of various actors within public health system and co‑ordination mechanisms between them Article 25 specifies that the Basque Government is responsible for planning and defining public health policies and strategies, while public and private health and non-health agents (notably Osakidetza), along with citizens, develop specific actions to implement them. Article 28 outlines the basic competencies for public health professionals. The Basque Health Plan (Plan de Salud de Euskadi) is the central regulation tool. with all regional, provincial (foral), and local (municipal) health plans, strategies and programmes aligning with it. The law establishes the Interinstitutional Commission on Public Health to share information and ensure the effective institutional co‑operation avoid overlapping or duplication of competences between the different administrations. Articles 44‑46 detail the co‑ordination mechanisms between the Basque Public Health System and the Basque Healthcare Service.

• The attribution of competences of various administrations. The law defines the competences of the Basque Government (Article 33) and of municipalities and other local entities (Article 34), assigning a support role to provincial governments. The Basque Government oversees the strategic direction, and institutional organisation of public health, including the information systems. It is also responsible for approving health benefits, controlling and authorising public health establishments, and exercising inspection and sanctioning powers. Municipalities are responsible for monitoring compliance with health standards relating to the environment, food production and distribution, and animals on their territory. They also develop programmes and plans for health protection and promotion, including addiction prevention. The law stipulates that central, provincial and local administrations will apply the law according to relevant sectoral legislation (e.g. health, education, sport, etc.). However, these guidelines are very general, leaving the more precise definition to the sectoral regulation. As a result, the absence of a sectoral law on community action in health creates some ambiguity in these activities.

• The Basque Institute of Public Health. This autonomous institute is submitted to the supervision of the DHBC. Its purpose is to centralise all public health functions currently assigned to the DHBC (specified in the Article 53 of the law). Law 13/2023 details the institute’s organisation, mission, and attribution of human and financial resources. Additionally, the law mandates the creation of a Public Health Information System to share, harmonise, and analyse key public health information and statistics across the Basque Country to improve policies.

Both the legal and regulatory framework and the institutional setup of the Basque Health System are the result of a historical evolution, which will continue to adapt to new health needs and societal changes. Understanding the current situation is crucial to guide and plan the development of policies to improve community health engagement. The next section explains how the DHBC is organised and its role in promoting community health in the Basque Country.

References

[11] Cassetti V, L. (2018), Participación comunitaria: mejorando la salud y el bienestar y reduciendo desigualdades en salud, Ministerio de Sanidad, Consumo y Bienestar Social, https://portal.guiasalud.es/gpc/participacion-comunitaria/.

[5] Departamento de Salud, Gobierno Vasco (2023), Plan de Salud Euskadi 2030, Servicio Central de Publicaciones del Gobierno Vasco, https://www.euskadi.eus/contenidos/informacion/publicaciones_departamento/es_def/adjuntos/plan-salud-2030.pdf.

[4] Departamento de Salud, Gobierno Vasco (2013), Políticas de Salud para Euskadi 2013-2020, https://www.euskadi.eus/gobierno-vasco/-/plan-gubernamental/12-plan-de-salud-2013-2020/.

[6] 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.

[8] Hernán, A. (2013), “Formación en salutogénesis y activos para la salud.”, Series monográficas Escuela Andaluza de Salud Pública, https://www.easp.es/project/formacion-en-salutogenesis-y-activos-para-la-salud/.

[9] iLab (2020), Guía para una participación generadora de bienestar y salud, https://www.ogp.euskadi.eus/contenidos/proyecto/ogp_compromiso_3/es_def/adjuntos/Guia_ILAB.pdf.

[7] Marchioni, M. (2013), Metodología de la intervención comunitaria, Fundación CeiMigra, https://saludcomunitaria.files.wordpress.com/2014/03/2-metodologia-de-intervencic3b3n-comunitaria.pdf.

[2] Ministerio de Sanidad de Espana (2021), Acción comunitaria para ganar salud ... o cómo trabajar en común para mejorar las condiciones de vida, https://www.sanidad.gob.es/areas/promocionPrevencion/entornosSaludables/local/estrategia/herramientas/docs/Guia_Accion_Comunitaria_Ganar_Salud.pdf (accessed on 1 February 2024).

[3] Ministerio de Sanidad de España (2019), Participar para ganar salud, https://www.sanidad.gob.es/areas/promocionPrevencion/entornosSaludables/local/estrategia/herramientas/docs/Guia_Participar_ganar_salud.pdf.

[10] NICE (2016), Community engagement: improving health and wellbeing and reducing health inequalities NICE guideline, http://www.nice.org.uk/guidance/ng44.

[1] OECD (2022), Modernising Social Services in Spain: Designing a New National Framework, OECD Publishing, Paris, https://doi.org/10.1787/4add887d-en.

Notes

← 1.  Although the means of participation defined in Article 67 of Law 16/2003 do not correspond to what is understood as community action in health in the literature, the article is interesting as it clearly shows the legislator’s intention to give users an active role in defining health policies in Spain.

← 2.  The denomination of the specialty of primary care medical doctors (and same with nurses) in Spain is “primary and community care”. This denomination was coined in the 80´s and responds to historical circumstances. Indeed, there is a clear and shared interest for the medical profession (doctors and nurses) adopting a community perspective, but this genuine interest does not imply that the locus of community action is exclusively primary care.

← 3.  For more information about Asturias Actúa check here: https://saludcomunitaria.wordpress.com/‌category/asturias-actua‑en-salud/.

← 4.  The Basque Public Health System (Sistema de Salud Pública de Euskadi) is created by Law 13/2023 and refers to a large network of services, programmes and institutions that have an impact in public health, whereas the Basque Health System (Sistema Sanitario de Euskadi) was created by the Basque Health Organisation Act in 1997 and guarantees the provision of health services.