COVID-19 in Spain: a predictable storm?

As of Oct 12, there have been 861 112 confirmed cases and 32 929 deaths due to COVID-19 in Spain. More than 63 000 health-care workers have been infected. Spain was one of the most affected countries during the first wave of COVID-19 (March to June), and it has now been hit hard again by a second wave of COVID-19 infections. While the reasons behind this poor outcome are still to be fully understood, Spain's COVID-19 crisis has magnified weaknesses in some parts of the health system and revealed complexities in the politics that shape the country.

The COVID-19 pandemic tested health system resilience and pandemic preparedness. Despite the creation in 2004 of a Centre for Coordination of Health Alerts and Emergency, the pandemic laid bare the country's “weak surveillance systems, low capacity for PCR tests, and scarcity of personal protective equipment and critical care equipment, a delayed reaction by central and regional authorities, slow decision-making processes, high levels of population mobility and migration, poor coordination among central and regional authorities, low reliance on scientific advice, an ageing population, vulnerable groups experiencing health and social inequalities, and a lack of preparedness in nursing homes”, according to 20 Spanish public health leaders writing in August in The Lancet.

The Spanish health system's four pillars—governance, financing, delivery, and workforce—were already fragile when they were overwhelmed by COVID-19 in March. A decade of austerity that followed the 2008 financial crisis had reduced the health workforce and public health and health system capacities. Health services are understaffed, under-resourced, and under strain. With 5·9 nurses per 1000 inhabitants, Spain has one of the lowest ratios in the EU (where the average is 9·3 per 1000), and too often relies on temporary contracts that can run for just a few days or weeks.

Granular data surveillance is key for understanding and responding to an outbreak. For Sergi Trias-Llimós and colleagues, writing in The Lancet Public Health, the data currently published at the country and regional levels are insufficient to understand the dynamics of the epidemic. They call on authorities to provide comprehensive data updates on tests, cases, hospitalisations, intensive care unit admissions, recoveries, and deaths, all disaggregated by age, sex, and geography.

The test-trace-isolate tryptic, which is the cornerstone of the response to the pandemic, remains weak—COVID-19 cases are increasing alarmingly, and authorities are again looking at lockdowns to contain the spread of the virus. When the national lockdown was lifted in June, some regional authorities were probably too fast at reopening and too slow at implementing an efficient track and trace system. In some regions, the local epidemiological control infrastructure was insufficient to control future outbreaks and limit community transmission. Spain's political polarisation and decentralised governance might also have hampered the rapidity and efficiency of the public health response. Whereas the first wave might have been unpredictable, the second wave in some parts of Spain was quite predictable, Rafael Bengoa (Institute for Health and Strategy, Bilbao, and former Minister of Health Basque Country) told The Lancet Public Health.

In an attempt to identify areas where public health and the health and social care system need to be improved, Alberto García-Basteiro and colleagues, in their Letter in The Lancet Public Health, urged the Spanish central and regional governments to set up an independent evaluation of their COVID-19 responses, and lay down the requirements and principles for such an evaluation. The evaluation should start immediately, should build consensus among society, and requires firm commitment from the central and regional governments; the evaluation committee should be independent, diverse and multidisciplinary, the evaluation should be broad in scope (health, economic, and social effects) and providing recommendations. Such an independent evaluation will be key to reassure the population and rebuild trust in the Government's approach to public health.

And there are reasons for hope. In the latest Global Burden of Disease analysis, published in The Lancet, health indicators (such as life expectancy and healthy life expectancy) suggest that Spain overperforms, with indicators better than would be predicted according to the country's socio-demographic index. If Spain's political leaders can draw the lessons from their sub-optimal response to COVID-19, the country is very well placed to give its population a bright and healthy future.