Global Health Experience
In her seminal book, Health, Civilization and the State: a history of public health from ancient to modern times, the academic historian, Dorothy Porter, defines public health as “collective action in relation to the health of populations”. Of the many definitions of public health that exist, this has always been my favourite because it de-medicalises public health, shifts attention away from professional groups or infectious diseases, and emphasises the central importance of people working together to improve the health and well-being of communities. In my global health experience, nowhere in the world has this definition felt more apt than in Catalonia.
Over the past six months I have had the privilege of being part of a team of experts, convened by the World Health Organization, and tasked — at the request of the Regional Minister of Health (Conseillera) — with reviewing the health system in Catalonia. Working hand-in-hand with WHO staff, the team was asked to examine the health and healthcare system across this semi-autonomous region of Spain, giving particular thought to how the planning process has evolved over time: my focus was on reviewing the public health system, including its integration with health and care services. The work has involved scrutinising a wealth of documents, web-discussions, and two visits to the region during which facilities were visited and interviews were conducted with a large number of staff.
Catalonia sits in the north-east of Spain, an area of stunning geography including sea, mountains, striking city-life, and beautiful countryside. Of the 17 semi-autonomous regions (or ‘autonomous communities’) in Spain, Catalonia is the second most populous with more than seven million people, and is sub-divided into four provinces: Barcelona, Girona, Lleida and Tarragona. Over a third of the population of Catalonia resides in the municipality of Barcelona, though in total there are more than 900 municipalities across the region, many of which are home to small rural communities. This combination of a dominating large metropolis alongside smaller urban and rural localities contributes to Catalonia’s particularly complex public health system: the other elements that play into this complexity include history, politics, economics and cultural identity.
As in many other settings world-wide, the public health system in Catalonia comprises two main arms: the health system component under the Ministry of Health, including the Catalan Public Health Agency (ASPCAT) whose professional workforce has operational reach into all four provinces; and the local government (municipality) component with staff at urban, regional and local levels contributing to public health activities and projects. One particular challenge for Catalonia is that while health is essentially a devolved function (Catalonia can set its own health strategies, manage its own health services, and choose how to spend its devolved health budget), the local authority system across the whole region remains overseen by Spain’s national government, including the national setting of policies and control over money.
The different funding streams and differential policy-setting between the two arms of the public health system means, in theory at least, that there could be conflicting sets of heath priorities. In practice, this is less than expected, not least on account of a fairly ground-breaking Inter-ministerial Public Health Plan (PINSAP), which helps bring together those two arms — as well as other government departments — in support of a shared public health agenda (covering the relationship between health and an array of factors including the environment, diet, employment, housing, town-planning, education, physical activity and culture).
In terms of health experience in Catalonia, life expectancy is good for women (85.9 years) and fairly good for men (80.4) — though the gender difference disappears for healthy life expectancy (both just under 70) — and infant mortality rates are below those for the whole of Spain and the European Union. Nearly 40% of the population, however, suffers a long-term health condition, and levels of overweight are high for adult men (43.2%) and less-so for women (27.3%), a gender difference mirrored in obesity levels in young children. Tobacco consumption in those aged over 15 is high at 25.6% (30.9% for men and 20.5% for women: over the past two decades rates have fallen for men but hardly at all for women), and binge drinking is a particular problem for those aged 14 to 18. Interestingly, despite the concerning prevalence levels for smoking, stroke survival rates are strong, reflecting positive progress on hypertension reduction and good health services.
Overall, the public health system in Catalonia works well — especially around communicable diseases — so the issue is really how to help the system go from ‘good’ to ‘excellent’. Following the review, recommendations to support such a transition were made and include: a) co-creation of the upcoming new version of PINSAP, so it moves from a valuable document that supports cross-government ‘health-in-all’ thinking, to a clear public health road-map that is developed and owned across sectors, departments, geographical levels and stakeholders — under-pinned by specific public health strategies such as tobacco control and tackling obesity; b) creation of a public health workforce development plan that addresses competencies, training, multi-disciplinarity, working conditions, leadership skills, and establishment of a culture of learning [around 50% of the Public Health Agency professional workforce are currently vets, which is probably not sustainable or appropriate]; and c) attention to knowledge development and exchange, for instance through creation of a web-portal for publicly accessible public health data at all levels [like Public Health England’s ‘Fingertips’], and creation of mechanisms for sharing good practice, sharing learning and celebrating successes.
All in all, there is a huge amount to admire in the public health system and in the provision of population health services in Catalonia. Despite relatively modest investment outcomes are generally good, and other high income countries could learn much from inspection of how public health operates in north-east Spain. Yet, it feels like there is more to this success story than meets the eye, that there is a deeper contributory factor, a kind of secret ingredient that bonds the system together: something hard to quantify and hard to put your finger on. That particular characteristic, I believe, which sits at the very heart of public health in Catalonia is solidarity. Solidarity in both the staff and in the population that enables highly effective ‘collective action’.
But what exactly is solidarity? It certainly represents a community-spiritedness and feeling of togetherness that is palpable when talking to those working or living in this part of Spain. For example, on a visit to the fantastic La Mina Primary Care Centre, we were shown a plaque on an outside wall of the building near the main entrance. Not uncommon, I thought initially, but this particular plaque was donated by the local population in thanks to the healthcare staff for their work and community commitment. Something I’ve never seen before. Conversations with staff at the centre illustrated that it was completely routine for them to accompany residents on walks into the hills as part of ‘exercise on prescription’, professional boundaries virtually non-existent.
Further behind the notion of community spirit, however, solidarity reflects an even more basic human trait — that of caring for, and caring about, those around you. Caring for others is an innate human attribute: you see it in toddlers even before it is learned and, without such an attribute, families, community groupings and the world just couldn’t function. Yet, like so many attributes that are in our DNA, ‘caring for others’ can easily erode over time, as personality labels and life’s inevitable pressures take their toll. Thankfully, that seems not to be the case in Catalonia, where solidarity within the population holds strong, evidenced by the adorned yellow ribbons of support for their imprisoned political leaders — a sign of how people should, or shouldn’t, be treated, rather than a position statement for or against Catalonian independence. Collective action of a different sort, but collective solidarity nonetheless.
December 11th 2019