Stewardship of the Spanish National Health System

international journal of health planning and management

Int J Health Plann Mgmt 2010; 25: 386–399.

Published online 6 May 2010 in Wiley Online Library

(wileyonlinelibrary.com) DOI: 10.1002/hpm.1046

Stewardship of the Spanish National HealthSystem

Vaida Bankauskaite1* and Christina M. Novinskey2

1Departamento de Inteligencia Artificial, Facultad de Informatica, Universidad Politecnicade Madrid, Boadilla del Monte, Madrid, Spain2Social Policy Department, London School of Economics and Political Science, London, UK

SUMMARY

Along with resource generation, financing, and health service delivery, stewardship is a keyhealth system function. However, very little empirical analysis has been carried out on it. Thispaper aims to fill this gap in the literature by assessing the Ministry of Health’s (MoHs) role asa steward of the Spanish National Health System (NHS) after the 2001 decentralization reformof health care management to the Autonomous Communities. We use the following steward-ship framework with six sub-functions for the analysis, looking at the MoH’s ability to: (1)formulate strategic policy framework; 2) ensure a fit between policy objectives and organ-izational structure and culture; (3) ensure tools for implementation; (4) build coalitions andpartnerships; (5) generate intelligence, and (6) ensure accountability. We describe thestewardship function, identify existing challenges and issues in the Spanish case, and reflectupon methodological aspects of this exercise. We use reports, documents, articles, and officialstatistics to complete the analysis. Overall, we find the MoH to give an average performance inits role as the steward of the health system. The MoH has progressed particularly well ingenerating intelligence as well as formulating a strategic policy framework over recent years.However, it lacks the appropriate authority to efficiently coordinate the health system and toensure that the Autonomous Communities implement policies that are in-line with overallNHS objectives. Copyright # 2010 John Wiley & Sons, Ltd.

key words: Stewardship; health systems; decentralization; Spain

INTRODUCTION

With its seminal report in 2000, the World Health Organization (WHO) deemed

stewardship one of four major health system functions, ranking it in importance

above the other functions of resource generation, financing, and health service

delivery. It defines stewardship as ‘‘the careful and responsible management of the

well-being of the population’’ (WHO, 2000, p.45). Despite this, stewardship has

proven an elusive topic in the literature. This paper fills this gap in the literature by

analyzing the stewardship function of the Spanish National Health System (NHS).

*Correspondence to: V. Bankauskaite, Departamento de Inteligencia Artificial, Facultad de Informatica,Universidad Politecnica de Madrid, Boadilla del Monte, Madrid 28660, Spain.E-mail: [email protected]

Copyright # 2010 John Wiley & Sons, Ltd.

STEWARDSHIP OF THE SPANISH NHS 387

In most governments, the Ministry of Health (MoH) or Secretariat of Health plays

the steward of the health system because it is the central government institution

responsible to guarantee the population’s welfare as well as the health system’s

performance. As the steward, it makes policies for and regulates the health system,

providing a clear and consistent strategic direction of the system (Travis et al., 2003).

This paper has two objectives: analyze the stewardship role of the Spanish NHS by

sub-function to identify areas for its improvement and advance the literature on the

concept of stewardship through empirical evidence.

METHODS

We employ Travis et al.’s (2003) comprehensive stewardship framework for health

systems in our analysis of the Spanish NHS. This framework is based on six sub-

functions of stewardship; the steward’s ability to

(1) f

1Offiand C2Incl

Copy

ormulate strategic policy framework;

(2) e
nsure a fit between policy objectives and organizational structure and culture;
(3) e
nsure tools for implementation: powers, incentives, and sanctions;
(4) b
uild coalitions and partnerships;
(5) g
enerate intelligence; and
(6) e
nsure accountability.
The Spanish MoH1 is the main protagonist of our analysis.

Providing context for the analysis, we briefly describe the Spanish NHS as well as

the macro-economic, political, and institutional factors that surround it. Next, we

describe each sub-function of stewardship and analyze the performance of the MoH

as the steward of the health system. Finally, we discuss our main findings and draw

conclusions.

We base our analysis on a literature review—including official documents,

reports, statistics and gray literature, in-country ground work as well as stakeholder

interviews.

Spain and the organization of the Spanish NHS

Spain is a high-income country and member of the OECD. Until the beginning of the

current global economic crisis, it experienced a 10-year economic boom. In 2005,

Spain spent 8.3% of its Gross Domestic Product (GDP) on health, with a total per

capita expenditure of US$2242 Purchasing Power Parity (See Table 1). Its general

government expenditure on health2 was 71.4% of total health expenditures, while

out-of-pocket expenditure on health was only 21.9% of the total. With lower fertility

and higher life expectancy rates than the EU average, Spain’s most prominent health-

related trend today is the rapidly aging population.

cially referred to as theMinisterio de Sanidad y Consumo, which translates to the Ministry of Healthonsumer Affairs.

uding all government revenue (central and regional).

right # 2010 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2010; 25: 386–399.

DOI: 10.1002/hpm

Table 1. Macroeconomic, health expenditure, and health indicators of Spain and EuropeanUnion 27, 2005

Macroeconomic and health expenditure indicators Spain EU 27

GDP per capita (current $) 26 166 29 614Total expenditure on health as % of GDP 8.3 8.9Total expenditure on health, US$ PPP per capita 2242 2468Public sector health expenditure as % oftotal health expenditure, WHO estimates

71.4 75.5

Private households’ out-of-pocket paymenton health as % of total health expenditure

20.9 17.2

Health and mortality indicatorsLive expectancy at birth, in years, male 77.1 75.4Life expectancy at birth, in years, female 83.8 81.6Fertility rate, total (births per woman) 1.3 1.5Standardized death rate (SDR), disease ofcirculatory system, all ages per 100 000

171.9 271.2

SDR, malignant neoplasms, all ages per 100 000 159.7 179.2

Source: European Health for All database (HFA-DB). Copenhagen, WHO Regional Office forEurope, [2008] (http://www.euro.who.int/hfadb).

388 V. BANKAUSKAITE AND C. M. NOVINSKEY

Spain is a unitary state composed of four tiers of government: central, regional

(Autonomous Community, or AC)3, provincial, and municipal. Under the precepts of

the NHS, its top two tiers of government share responsibility for providing health

care services to the population. The 1986 General Health Law (GHL) makes the

MoH legally responsible for promoting the coordination and cooperation of the

health sector. Besides operating their own governments and parliaments, since 2001

the 17 ACs have decision-making power over health care service management

(including planning and organization).4 Furthermore, the Minister of Health and the

Regional Health Ministers (Consejeros de Salud) compose the highest coordinating

body of the NHS: The Interterritorial Council (CISNS).5

The Spanish NHS is characterized by political decentralization (or devolution)—a

broader policy of the government and a core principle of the 1978 Constitution.

Devolution of decision-making powers for health service management from the

central government to the ACs began in 1981 with Catalonia. Since then, these

powers were gradually devolved across all of the ACs until 2001, when they were

transferred to the last 10 ACs all together. In a devolved context, the MoH plays the

‘‘steward of stewards’’ and is ultimately responsible for ensuring the collective

provision of effective stewardship over the system (Travis et al., 2003).

3There are also two autonomous cities: Ceuta and Melilla. These cities are not included in the studybecause they are exceptional in many ways.4Each AC has subdivided its territory into health areas and zones. The health areas are responsible for themanagement of facilities, benefits, and health service programs, and each health zone for a single PrimaryCare Team (Duran et al., 2006).5Created in an Act in the 1986 General Health Law and later modified by the 2003 Law for NHS Cohesionand Quality.

Copyright # 2010 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2010; 25: 386–399.

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Financing for the NHS also changed with the devolution of health service

management. The NHS is largely funded by general revenues. The ACs receive the

majority of their financial resources for public services (including health) from

the central government.6 In addition, they have some revenue-raising powers over

direct taxes.7 The last financing agreement of the NHS was set in 2001, coinciding

with the devolution of health service management to the ACs.8 This agreement

changed the flow of funds for health. Previously, there was a health fund separate

from the general fund; now, the health fund has been integrated into the general fund

and, thus, all previously held earmarking of financial resources for health has been

removed.9

FINDINGS

In the following, we describe each sub-function of stewardship according to Travis

et al. (2003) and modifications that we apply to it. We, then, analyze each one within

the context of the Spanish NHS, taking the MoH as its primary steward from 2001

onwards.

Formulating strategic policy framework

A key function of stewardship is the steward’s ability to formulate a strategic policy

framework for the NHS. The steward should articulate a vision for the system as well

as short- and long-term goals and objectives. It is also responsible for clearly defining

the roles of the public, private, and voluntary health sectors. Moreover, it should

outline feasible strategies, guide the prioritization of health expenditures, and

monitor the performance of sub-central health services (Travis et al., 2003; 2001).

The SpanishMoH’s mission is to guarantee equity, quality, and social participation

of the NHS and the active collaboration of system stakeholders for the reduction of

health inequalities. Its vision and goals are legally founded upon a series of clearly

elaborated laws: from the 1986 GHL to the 2003 Law for Cohesion and Quality of the

NHS (LCQ). Through the GHL, it is legally responsible for the coordination and

cooperation of the NHS and its various stakeholders, most importantly, the health

services of the ACs (or regional health services). Through the LCQ, the MoH is

jointly responsible (with the ACs) for developing quality assurance strategies for the

NHS. Accordingly, it has developed the accreditation system for health units and the

basic health service package (Bohigas Santasusagna, 2007). To ensure performance,

it carries out activities such as policy design, monitoring, and evaluation. In relation

to policy design, in 2004, the MoH published a Strategic Plan for Pharmaceutical

6Except the Basque Country and Navarra, who have enjoyed their own revenue-raising power as historicalrights set out in the 1978 Spanish Constitution.7These are generally not utilized because raising taxes is an unpopular policy.8Approved by the National Council for Financial and Fiscal Policy (Act 21/2001, 27 December 2001). Anew agreement is currently undergoing revision for 2009.9With the new agreement, the ACs are required de jure to allocate a minimum amount of their expenditureto health care services. This amount, however, is easily met as it is relatively low compared to generalhealth expenditures.


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Policy and, in 2006, adopted a law10 to guarantee the rational use of medicines and

health products in the NHS. The latter law granted the MoH with exclusive authority

over pharmaceutical legislation in the country. Furthermore, the MoH is responsible

for external relations and the management of the Nutrition Alert Network and the

Environmental Surveillance Network.

The main principles of the Spanish NHS are the provision of universal and free

access to health care services, and the integration of all health service networks under

one structure. The ACs have been responsible for the implementation of these

principles since 2002. As such, each AC holds health care planning powers as well as

the capacity to organize its own health service with the level of de/centralization that

it considers most appropriate for its health zones and areas. Although almost all ACs

have a health plan based on principals that stem from the WHO’s Health For All

Strategy (which encompass the main principles of the Spanish NHS), they are at

different stages of development (a possible consequence of devolution). Often, they

address the same issue to a different extent, as is the case of gender sensitivity (Peiro,

2004).

Ensuring a fit between policy objectives, organizational structure, and culture

This sub-function encompasses the overall architecture of the health system and its

capacity for implementation. Ensuring a fit between policy objectives, structure, and

culture of the health system is important for MoH to successfully achieve its goals.

Moreover, the better the fit, the more the system can minimize undesirable overlap,

duplication and fragmentation of its health services and functions.

As established by the 1978 Spanish Constitution, the NHS has a decentralized

organizational structure. As such, coordination is essential to the proper operation

and achievement of goals. According to Sevilla Perez (2006), there are three levels of

coordination within the Spanish NHS: (i) between the ACs; (ii) between the ACs and

the State; and (iii) between the publicly financed health services that make up the

NHS. However, the law does not explicitly stipulate how this coordination should be

carried out, making coordination a challenge in practice (Rey del Castillo, 2007).

The CISNS has had difficulty putting its vision into practice. The CISNS was

established by the 1986 GHL as the NHS’s permanent body of coordination,

communication, and information. It also regulates the operation of the NHS. Prior to

the 2003 LCQ, the CISNS was composed of 34 members: 17 central government

representatives (headed by the Minister of Health) and one representative from each

AC. With the implementation of the LCQ, the number of total members was reduced

to 18, including the National Minister of Health and the 17 AC representatives. The

CISNS has been blamed for its highly politicized character and limited executive

power. The CISNS has neither retained authority to exercise executive power over

the NHS nor has it formed a collegiate body or applied majority rules. It is a platform

for political confrontation rather than consensus and collaboration. Its activities—

including meetings, discussion topics, task forces, and commissions—have been

patchy and ad hoc since its establishment, and agreements and decisions have not

10Law 29/2006, on the 26 of July.


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been implemented in many of cases (Muzquiz Vicente-Arche, 2007). As a

consequence, the work of the CISNS has experienced major performance

deficiencies, for which it is frequently criticized.

The MoH and the central government’s roles in the health system were weakened

by the change in the composition of the CISNS. In addition, with the 2001 devolution

reform, the MoH lost its role as health care service manager of the National Institute

of Health (INSALUD).11 In hindsight, it would have been ideal to strengthen the

MoH’s role on the CISNS immediately after or in parallel to the devolution reform

(Muzquiz Vicente-Arche, 2007). Instead, this was attempted in 2003 with the LCQ,

which has had very little influence. More recently, it has been suggested that theMoH

could act as the negotiator of the CISNS to first and foremost ensure that the ACs do

not take decisions that would harm or undermine each other. If undertaken, this may

also provide the MoH with more power to promote measures that reduce health and

health care inequalities across the ACs.

Ensuring (formal) tools for implementation: powers, incentives, and sanctions

It is further the responsibility of the steward to ensure that the appropriate tools for

implementation exist as well as to facilitate the execution of policies adopted by the

NHS. At this sub-function’s core, the powers of the steward must be coherent with its

responsibilities. The steward must also take action to set and enforce appropriate

rules, incentives, and sanctions for the other NHS stakeholders (Travis et al., 2003).

The 2001 reform left the MoH with insufficient powers to appropriately enforce

rules, incentives, and sanctions over NHS entities. The 2003 LCQ further failed to

outline any financial instruments for NHS coordination (Rey del Castillo, 2007).

Since, there has been much discussion on a lack of cohesion of the system; however,

there is little consensus on how to improve it. For example, Andalusia and Castile-La

Mancha support increasing theMoH’s role on the CISNS as well as the establishment

of a permanent commission with capacity to enforce compliance with adopted

agreements. Catalonia and the Basque Country, however, support greater executive

power for the permanent commission option and less so for theMoH (Trujillo, 2009).

Moreover, while reducing health inequalities remains an important agenda issue, the

financing formula for the ACs do not include appropriate incentives or rules to

achieve this. There is a supplementary fund to the ACs, the Cohesion Fund12, which

guarantees portability of health care across the ACs; that is, it covers patient expenses

incurred in ACs that are not their own and allows each AC to bill others for services

rendered. However, it excludes compensation for primary health and emergency care

services as well as pharmaceutical expenses (Gonzalez Lopez-Valcarcel and Barber

Perez, 2006).

The MoH has worked jointly with the ACs to plan for the system. Mandated by

both the GHL and the AC health laws, the development of these health plans has been

a major achievement for the system (Gispert et al., 2000). Health plans serve as

principal instruments for identifying activities and planning resources towards the

11Health care service provider of the 10 ACs without this competency before the 2002.12Real Decreto 1247/2002.


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attainment of both health and NHS goals. Despite some variability in design and

content, the various AC health plans and the MoH’s 1995 health plan share the same

purpose: responding to identified health needs and offering action strategies (Duran

et al., 2006). Within their health policy strategy, most ACs have developed

Multiannual Quality Plans and some have established their own accreditation

entities. For example, in 2002, Andalusia created the Agency for Quality in Health,

which is responsible for regional accreditation programs of health professionals and

centers (Ministry of Health and Consumer Affairs, 2006).

According to theWHO framework, the rights and responsibilities of health system

users should be defined by the steward (Travis et al., 2003). The 1986 GHL specifies

user rights to the system, including rights to human dignity, information, and the

existence of complaint procedures. Article 10.12 of this Law recognizes and

guarantees the right of any citizen to issue a complaint. The Patient’s Freedom of

Information Act (PFIA) further extends patient rights with freedoms to choose a

doctor or health care center and to receive waiting list information. In practice,

patient rights are guaranteed through ensuring that all health centers display

guidelines regarding user rights and obligations, lists of available services and

procedures for submitting suggestions and complaints. In case of litigation, it is

increasingly common for the ACs to create specific units (e.g., Patient Support

Services) within their ranks to represent patients along with their complaints (Duran

et al., 2006).

Patient security and occupational health care are additional policy areas where the

MoH plays an active role. Patient security is one of 12 priorities included in the 2006

National Quality Plan for the NHS, which outlines five fundamental strategies for

strengthening patient security (Ministry of Health and Consumer Affairs, 2006). This

Plan has had a decisive impact upon the AC plans. According to the NHS annual

report, 10 out of 17 ACs carried out institutional surveys on patient security in 2006.

In addition, several central-level acts regulate occupational health; most

significantly, Law 31/1995 on the prevention of occupational risks (Government

of Spain, 1995) and Law 54/2003 on the normative framework reform for the

prevention of occupational risks (Government of Spain, 2004).

Article 22 of the LCQ authorizes the MoH, along with the CISNS, to regulate the

utilization of certain techniques, technologies, and procedures, and to determine

their inclusion in the NHS benefit package. This paper aims to establish the degree of

safety, efficacy, efficiency and/or effectiveness of the technique, technology or

procedure before deciding on its inclusion. In 2005, the MoH carried out the first

national study on adverse effects in health care. Results point to improvements in

monitoring and evaluation, and the control of adverse effects from pharmaceuticals,

hospital infections, anesthesiology, and surgery.

Building coalitions and partnerships

Factors outside the steward’s realm impact on health and, thus, it is wise—and

necessary in a decentralized system—for the steward to build effective coalitions

and partnerships to promote changes within the system. Partnerships and coalitions

vary on a relationship continuum that stretches from loose affiliations to legally


DOI: 10.1002/hpm


binding relationships (Rhodes, 1991). They can be established for ongoing activities

or one-off issues or events; for instance, to develop a new policy or a media

campaign. The parties involved may include professional associations, patient or

consumer groups, ministries outside that of health, private enterprises, medical

schools, the pharmaceutical industry, research foundations, politicians at all

government levels, NGOs, among others (Travis et al., 2003). In the following, we

examine a few key partnerships with Spanish MoH.

The Council of Fiscal and Financial Policy13 is an example of a successful public

partnership with the MoH. Established in 1980, the Council coordinates financial

activities between the central government and the ACs. It is composed of the

Ministers of Economy and Public Administration and the Regional Ministers of

fiscal issues from each ACs. The Council has the power to take executive decisions,

which has allowed it to play a decisive role in developing financial mechanisms and

agreements regarding the NHS and its implementation at the regional level.

Created in 1987, the CISNS is an example of a partnership directed by the MoH.

Decisions taken by the CISNS are adopted by consensus and take the form of

recommendations as they affect matters that have been decentralized to the ACs. In

some cases, the ACs and central government can sign ‘‘covenants’’ or ‘‘agreements’’

that oblige both parties. The lack of real executive strength of this body, however, has

caused great inefficiencies for the NHS (Elola, 2004; Repullo Labrador et al., 2004).

The CISNS has encountered substantial problems guaranteeing equal access to

deprived social groups, consolidating a stable financing system, containing costs, and

coordinating and integrating the health services of the different ACs.

For occupational health issues, the MoH works together with the National

Commission of Safety and Health at Work. This commission is a collegiate body of

the Public Administration, whose responsibility is to formulate policy for the injury

prevention and health promotion at work.14 It is composed of representatives from

the Public Administration, the ACs and cities as well as businesses and trade unions.

Much due to the vast representation of stakeholders, this Commission has

successfully designed and implemented occupational health policies.

The MoH has pursued other successful partnerships with, for example, the

National Statistics Institute, the Ministry of Economy and Finance, and the Institute

of Health Carlos III.

The generation of intelligence

The generation of intelligence in the NHS creates an evidence-base for decision-

making and, when put to effective and good use, it can improve health outcomes.

Intelligence includes reliable, up-to-date information on: (i) important contextual

factors, (ii) the actors that influence the NHS, (iii) current and future health and

health system performance trends, and (iv) possible policy options, based on national

and international evidence and experience (Travis et al., 2001, 2003). Information on

important contextual factors in OECD countries is generally readily available and

widely accessible; Spain is no exception. Intelligence on actors is particularly

13El Consejo de Polıtica Fiscal y Financiera.14Article 13 of the Prevention of Labor Risk Law (31/1995, 8 November).


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important for agenda-setting and for designing political strategies to improve the

probability of policy adoption (Roberts et al., 2004). This type of intelligence is

difficult to analyze for this exercise as often most information in this regard is

confidential or undocumented. The third and fourth types of intelligence are directly

related to the role of the MoH to ensure the production and dissemination of data and

outline possible policy options for the NHS. In the following, we analyze the MoH’s

provision of these last two types of intelligence.

The MoH has passed several laws that directly relate to the generation of

intelligence on current and future trends in health and NHS performance. The legal

background of the NHS information system consists of the three main laws and

regulations: (i) the GHL, 14/1986; (ii) the PFIA, 41/200215; and (iii) the LCQ, 16/

2003. The GHL stipulates the fundamental exchange of information within the NHS.

The PFIA specifies the patient’s freedom of information and the rights and obligation

of the system to provide medical information and clinical documentation. It also

provides the foundation of the national IT strategy16 for the health sector and

introduces a minimum content of information that each AC is required to provide.

The LCQ creates a health information system and a health information institute

under the auspices of the MoH (Alfarro Latorre, 2006).

The standardization and harmonization of health data and information systems

across the ACs have proven a big challenge for the NHS. Since devolution of NHS

was gradually implemented over two decades, the information systems of the ACs

are in different stages of development. While some of the ACs began developing

sophisticated information systems in the late 1980s (e.g., the Basque Country), others

only began doing so with the 2001 reform. Moreover, most ACs have independently

developed the applications for their information systems. After 2001, all ACs had

equal power to make ‘‘how-to’’ choices over NHS functions, including the right to

decide what information may be collected, how to collect it, and how to measure it.

With 17 different ACs, the process of standardization and harmonization of health

data and information systems is complex. The MoH, through the CISNS, established

the definition and standardization of data and flows, the selection of indicators and

the technical requirements that are needed for the integration of information with the

highest reliability possible (Gonzalo, 2007). In accordance, the ACs provide the

information, while theMoH reciprocates with its publication and dissemination to all

users. According to Anton Beltran (2006), standardization of these different systems

has started; however, a lot remains to be done.

The MoH has broken new ground in coordinating efforts to make medical records

compatible across the ACs. The transfer of patient records between health facilities

in different ACs would, foremost, lessen the duplication of services. To achieve this,

a unique identification code imprinted on an Individual Health Card will be assigned

to each Spanish resident. The code should work for all contact between a patient and

the NHS and allow computerized access to clinical information input from anywhere

throughout the system. The common technical and operational mechanisms of the

15Ley 41/2002, de 14 de noviembre, basica reguladora de la autonomıa del paciente y de derechos yobligaciones en materia de informacion o documentacion clınica. BOE n.274 de 15/11/2002.16This is an essential component of the generation of intelligence.


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Individual Health Card have yet to be finalized. Currently, 11 ACs17 have adopted

one model, while the rest of them each have their own. A shared technical platform

has been developed between these different models, which should not only avoid

duplications in treatment but also discrepancies in the coverage allowance of

residents and in determining through which AC they receive health coverage.

Additionally, this should also help manage financing issues and inter-territorial

budget transfers in cases where health care is provided to a resident in an AC that is

not their own. Work on the inter-operability of Electronic Health Records has also

started and the first prototypes of electronic subscription have been elaborated.

Furthermore, the National Quality Plan for the NHS, launched in 2006, proposes

improvements for the NHS information system through methods that promote

harmonization between the ACs (Ministerio de Sanidad y Consumo, 2006).

TheMoH, along with the CISNS, has made further efforts to generate intelligence.

For example, the MoH developed the Minimum Basic Dataset for hospital

information systems in the early 1990s. This system permits the comparison of

hospitals across Spain using performance indicators and functions rather well.

However, with the rise in outpatient care, it requires some improvement.

Additionally, the CISNS initiated the Information System on Health Promotion

and Education, which provides information regarding the planning, management,

and evaluation of health promotion and education activities. Under the auspices of

‘‘coordination’’, the MoH lead an initiative to develop a set of key health indicators

to generate a fundamental, integrated, and systematic NHS information system. This

agreement will be executed by the MoH together with the ACs, utilizing the

Information Systems Commission of the CISNS. The MoH played a key role in

establishing Law 605/2003, which sets standards for the generation of information on

waiting lists for all ACs and its publication every semester by the MoH (Government

of Spain, 2003). In 2006, it also improved the management and classification of

pharmaceuticals. While the above improvements aimed at facilitating the inter-

operability of the NHS information systems at the central and regional levels of the

NHS, they also helped to ensure accountability through the dissemination and

transparency of information.

Ensuring accountability to the population

Finally, the steward needs to ensure that all system actors can be held accountable for

their actions. This generally means that, particularly in a decentralized system, the

central government is accountable to the sub-central governments as well as to the

whole population; while the sub-central governments are accountable to the central

government and to their specific populations. In the health sector, direct

accountability to a population18 is difficult to implement (Brinkerhoff, 2004);

rather, there is a longer chain of accountability between the population and the

government responsible for health personnel. Travis et al. (2003) recommend seven

17Including the 10 ACs under pre-2002management of INSALUD (Aragon, Asturias, the Balearic Islands,Cantabria, Castile La Mancha, Castile and Leon, Extremadura, Madrid, Murcia, and La Rioja) and theCanary Islands.18The ‘‘short-route’’ of accountability (World Bank, 2004; see chapter 3).


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commonly cited markers for accountability, including the level of access to political

representatives, and the existence and operation of interest groups, publishing rules

and independent watch-dog committees.

By taking action to generate and public information about the NHS, the MoH has

increased accountability throughout the system. It is also determined to provide

citizens greater transparency, in particular concerning the work of the CISNS

(Ministry of Health and Consumer Affairs, 2004). Moreover, it has put formal

mechanisms in place for the participation of the population in the planning and

management of the system; though, de facto, citizens lack power to participate

(Duran et al., 2006).

The ACs have employed diverse participation mechanisms to increase

accountability in the system. The most common of these, health boards19 are

employed in most ACs and, sometimes, at more local levels of the NHS. Also a

consequence of devolution, these boards are in different development phases across

territories; some having only one regional health board and others expanding to over

100 zone-level health boards. Other ACs have established boards that address

specific issues, such as immunizations, cardiovascular diseases, mental health, and

diabetes. Furthermore, some ACs have developed various accountability instruments

and mechanisms. For instance, Castile-La Mancha has adopted measures to improve

citizen access to information as well as their active participation in decision-making

(Ministry of Health and Consumer Affairs, 2006).

Furthermore, in 1994, the law on public hospital foundations set accountability

mechanisms for the public authorities at the health care organization level

(Government of Spain, 1994).

DISCUSSION AND CONCLUSIONS

This paper analyzed the performance of the MoH as the steward of the Spanish NHS

after the 2001 devolution reform, employing Travis et al.’s (2003) stewardship

framework. Our results show that the MoH made progress in formulating a strategic

policy framework and generating intelligence for the NHS; however, it lacks the

authority to ensure policy implementation at the AC level. Overall, the MoH

performs moderately for the remaining sub-functions. Although we do not focus on

health outcomes in this assessment of health system stewardship, we are able to

obtain valuable qualitative information on the challenges and issues facing this

function.

In general, challenges for the implementation of health policy have been

recognized in many countries and, as it was well noticed by Hunter et al. (2005), it is

the persistence of implementation failure that has encouraged governments to pay

greater attention to the regulatory function. While financing, resource generation,

and service delivery deal with health system performance aspects, the stewardship

function looks mainly at the regulation of these three functions and, thus, the

regulation of health system performance.

19Consejo de Salud.


DOI: 10.1002/hpm


The MoH performs averagely as the steward largely as a consequence of the

devolution reform. This reform failed to implement adequate mechanisms to

reinforce the authority of the MoH at the same time as it devolved health system

management responsibilities to the ACs; thus, creatingmajor difficulties for theMoH

to steer the system towards its core objectives. For example, the MoH often lacked

the authority and power to coordinate the AC health systems. In addition, it was

unable to regulate the ACs to ensure that their individual policies were not harmful to

the other ACs or the whole system (Sanchez Fernandez, 2007). Hunter et al. (2005)

recommend that governments pay more attention to regulation, a sub-function of

stewardship, for improved results of health policy implementation. Furthermore, the

MoH does not have the financial means to establish sufficient incentives or sanctions

on the ACs to ensure that they work towards the overall health system objectives. To

remedy this situation, some have advocated consolidating the NHS by giving the

responsibility of its coordination solely to the central government; however, this is

not on the current or future political agenda (Jimenez-Palacios, 2007). Others

propose a social pact for health or a recentralization of the NHS into one system that

is directed by the MoH (Del Barrio Seoane, 2008). Historically, however, ‘‘reform

talks’’ and reform implementation in Spain have been incoherent and, generally,

focused on legalities rather than results and outcomes (Torres and Pina, 2004;

Bohigas Santasusagna, 2007). Hence, while theMoH has achieved some stewardship

measures, it still requires further improvements to better the overall performance of

the health system.

In addition to the results of the analysis, this research has identified two main

issues concerning the methods. First, the framework for stewardship needs

improvement. We chose to apply Travis et al.’s (2003) stewardship framework

because it is recommended by the WHO and is the leading and most comprehensive

framework in the literature. Nevertheless, there are few important issues with it.

We found its breadth too great for an in-depth, case-study analysis of stewardship.

We also found some overlap between the sub-functions. Some of these aspects have

already been highlighted by the authors themselves: ‘‘Further work to more

thoroughly define domains/functions is required at the first instance’’ (Travis et al.,

2003). The analysis of the stewardship function may be looked at as an additional

instrument for assessing the health system, giving a comprehensive picture of issues

regarding health system governance. In this regard, one might review and incorporate

aspects of other tools to evaluate health system performance (see for example, Hsiao,

2000; Murray and Frenk, 2000, OECD, 2002; Arah et al., 2003).

Second, we faced problems in the collection and analysis of data for the various

sub-functions. To begin with, data and relevant information on the MoH’s role over

the Spanish NHS are lacking. Moreover, evidence-based information was rare. Most

health system frameworks are oriented towards health outcomes precisely because

health outcome information is more readily available. In addition, the current method

of qualitative analysis by sub-function does not allow for the efficient comparison of

performance across countries. One idea would be to identify specific (proxy)

activities and corresponding indicators for each sub-function. While this may make

comparison easier; however, it may be difficult to do for some sub-functions and the

use of indicators should be cautioned as they come with their own issues—such as


DOI: 10.1002/hpm


the development of a set of weights, the treatment of exogenous influences on system

performance, and the modeling of efficiency (Smith, 2002).

In conclusion, we recommend a re-assessment of the sub-functions to reduce

overlap as well as the addition of particular indicators for each sub-function to better

ensure both comprehensiveness and comparability between different country health

systems. Additionally, this is the first time to our knowledge that the stewardship

function has been analyzed comprehensively for a country. Thus, we would urge that

further empirical evidence on the stewardship function be pursued. The paper also

found that the good functioning of a steward is particularly essential to a

decentralized setting. Thus, we also recommend that future analyses take into

consideration the level of decentralization of the health system.

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Stewardship of the Spanish National Health System