Ernst Ellert, GAM Infomail no. 1217, 22 March 2023
A wave of protests by doctors, nurses and their supporters is developing in Spain against the deliberate run down of the public healthcare system. Strikes started in Cantabria in November, spread to Catalonia in January, Navarra in February and Valencia in March. Unionised workers in private hospitals plan to strike on March 30. Unions are demanding government funding so that everyone is entitled to free healthcare. Staff are unable to cope with the number of patients in A&E departments. The movement is taking place in the context of local and regional elections, due in May,
The movement’s epicentre, since January, is the Madrid region. There, Isabel Ayuso from the conservative People’s Party (PP) has governed since 2019, supported by the neoliberal Ciudadanos (Citizens) and the ultra-right Vox (The Voice). The march, on November 13, was attended by 700,000 people. This already took the movement to a new level but on February 12, 2023, a new record was set – one million on the streets. On March 1 and 2, hospital emergency wards went on strike. Ayuso responded by ordering 100% of staff to provide a “minimum service”. Another major demonstration was planned for 26 March.
The initiative “Primary Health Care for All” has adopted a strategy of civil disobedience. Its members are chaining themselves to health facilities. Cristina Sanz, a nurse, thinks it is right that the movement should adopt direct action since negotiations had led nowhere. Instead, she says, an exceptional situation has arisen because Ayuso even forbids the collection of signatures for petitions at work. Rosa López, spokesperson for the Summat union, is looking into filing a criminal complaint for undermining the right to strike through compulsory service.
Third-class primary care
In Madrid, which is rocked by corruption scandals, the disparity in health care is particularly acute. The capital factor means that it is the region with the highest average income. But with only ten per cent of the budget spent on primary care, it is far and away in last place. International standards that doctors and nurses want to enforce, on the other hand, provide for 25 %.
Spain once had a relatively well-equipped and inexpensive health system, especially in the area of primary health care. In the opinion of many doctors, this is being abolished with the aim of pushing people into private insurance. These policies are still relatively cheap, but only because the companies pass the patients back to the public health system in case of complications or expensive cases. Thus, despite comparatively low tariffs, the insurance companies are still making profits as long as this practice is maintained. What an insurance policy that also covers expensive cancer treatments and operations would cost is shown in the USA: several hundred euros per month.
Basque Country
In the Basque Country, resistance also arose against the liberalisation course adopted since 2010. On 24 February, 2023, there were large rallies with tens of thousands of people in Bilbao, San Sebastián and Vitoria. The background to this is that responsibility for health care lies with the regions, so there are protests everywhere. Manuel Ferran Mercadé, advisor to the “Spanish Association for Family and Community Medicine” (semFYC) and spokesperson for the primary care sector of the grassroots organisation “SOS Bidasoa” in Irun, noted that relatively few young people had participated in the rallies. But he also pointed out that all the unions mobilised.
In the health sector, as well as separate unions there are the general ones. Normally, the doctors’ and nurses’ unions, the Basque unions and the Spanish unions are at loggerheads. The Basque ELA and LAB prefer confrontation, the Spanish CCOO and UGT prefer social pacts. Today’s rare unanimity can be explained by the approach of the regional government, which shuns dialogue and only makes pronouncements and announcements. The UGT and CCOO have joined demonstrations in the Basque provinces against the policies of the federal government, in which the Basque Nationalist Party and Social Democracy set the tone.
Health Economics in Spanish
The Basque Country boasts the best health system in Spain. Nevertheless, employees and patients are taking to the barricades here, too. The reason for this is the brutal underfunding that began at the turn of the millennium, which has to do with the centralisation of the health system. Previously, there were two budgets: one for primary care and one for clinics. Their integration only began in the Basque Country 10 years ago. Here, too, there is now only one budget and one head. Most of the money went to the inpatient sector at the expense of primary care. The more primary care was bled dry, the more people ended up in hospitals for expensive treatment.
In terms of health expenditure, the Basque Country is above the national average, but it is below in economic output. There are fewer private clinics, as Mercadé notes, but a lot of money is spent on external advice and material is bought that no doctor has ordered.
The long waiting lists are justified by the lack of medical staff. However, in relation to the population size, it seems sufficient. Spain is the country with the second highest number of medical faculties in the world. But a good portion of those trained migrate to the private sector, not the public sector. Even fewer are found in primary care where there are poor working conditions and lousy pay. In view of the average training period of 11 years, a sensible planning in an integrated health system would be needed so that doctors and nurses can be deployed alternately in all positions and in all sectors with uniform training. The second prerequisite for this: abolition of the private health care system!
Staff shortages – just like in Germany
In a few years, 30% of doctors will retire and Spain will face a major staffing problem that cannot be solved by a short-term increase in the number of students. Our companies also complain about a shortage of skilled workers. Despite all the differences, in both Germany and Spain, clinics are the gateway for the entry of capital into the health sector. In Spain, this is at the expense of a rational system of basic care through integration, centralisation and privatisation of health care providers and health insurance companies.
In Germany, the hospital sector was already released from public financing by the municipalities in the early 1970s and a dual regime was introduced (operating costs reimbursed by the health insurance funds, investments by the federal states). Finally, a complete internal market (flat rates per case) was introduced, resulting in increased staff shortages, increasing work pressure, closures and privatisations as well as an excessive increase in scheduled operations on the one hand and redundancies for “unprofitable” cases on the other.
The triumph of neoliberalism, however, is increasingly hitting the former mainstay of the German health system – the doctors in private practice and their practices, which function like small businesses. In the form of medical care centres (MVZ), often linked to local clinics, competition is emerging that is reminiscent of the polyclinics of the DRR. However, today’s MVZs are only run for the purpose of maximum profitability, like the whole sick business that calls itself the health system. Its salvation, however, cannot lie in a return to the “idyll” of the small practices.
International connection
A comparison of the crisis in the health sector in Spain with Germany, as with practically all other countries in Europe, makes it clear that we are dealing with a transnational phenomenon. This also concerns the mobilisation of staff. But even though they are all the result of the capitalist crisis and neoliberal attacks, of austerity and privatisation, the struggles have so far been waged at the same time but nationally, or even locally, limited. Yet demands such as the nationalisation of the entire health care system under the control of workers and patients, for free and guaranteed access for all, and for sufficient funding and expansion of the health care system, paid for by the taxation of capital, are crying out for a common, internationally coordinated, movement.