international journal of health planning and management

Int J Health Plann Mgmt 2010; 25: 386399.

Published online 6 May 2010 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/hpm.1046

Stewardship of the Spanish National Health

System
Vaida Bankauskaite1* and Christina M. Novinskey2
1

Departamento de Inteligencia Artificial, Facultad de Informatica, Universidad Politecnica

de Madrid, Boadilla del Monte, Madrid, Spain
2
Social Policy Department, London School of Economics and Political Science, London, UK

SUMMARY
Along with resource generation, financing, and health service delivery, stewardship is a key
health system function. However, very little empirical analysis has been carried out on it. This
paper aims to fill this gap in the literature by assessing the Ministry of Healths (MoHs) role as
a steward of the Spanish National Health System (NHS) after the 2001 decentralization reform
of health care management to the Autonomous Communities. We use the following stewardship framework with six sub-functions for the analysis, looking at the MoHs ability to: (1)
formulate strategic policy framework; 2) ensure a fit between policy objectives and organizational structure and culture; (3) ensure tools for implementation; (4) build coalitions and
partnerships; (5) generate intelligence, and (6) ensure accountability. We describe the
stewardship function, identify existing challenges and issues in the Spanish case, and reflect
upon methodological aspects of this exercise. We use reports, documents, articles, and official
statistics to complete the analysis. Overall, we find the MoH to give an average performance in
its role as the steward of the health system. The MoH has progressed particularly well in
generating 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 to
ensure that the Autonomous Communities implement policies that are in-line with overall
NHS 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: vbankauskaite@hotmail.com

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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 populations welfare as well as the health systems
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 subfunctions of stewardship; the stewards ability to
(1)
(2)
(3)
(4)
(5)
(6)

formulate strategic policy framework;

ensure a fit between policy objectives and organizational structure and culture;
ensure tools for implementation: powers, incentives, and sanctions;
build coalitions and partnerships;
generate intelligence; and
ensure 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 reviewincluding 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, Spains most prominent healthrelated trend today is the rapidly aging population.
1

Officially referred to as the Ministerio de Sanidad y Consumo, which translates to the Ministry of Health
and Consumer Affairs.
2
Including all government revenue (central and regional).
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V. BANKAUSKAITE AND C. M. NOVINSKEY

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

Spain

EU 27

GDP per capita (current $)

Total expenditure on health as % of GDP
Total expenditure on health, US$ PPP per capita
Public sector health expenditure as % of
total health expenditure, WHO estimates
Private households out-of-pocket payment
on health as % of total health expenditure
Health and mortality indicators
Live expectancy at birth, in years, male
Life expectancy at birth, in years, female
Fertility rate, total (births per woman)
Standardized death rate (SDR), disease of
circulatory system, all ages per 100 000
SDR, malignant neoplasms, all ages per 100 000

26 166
8.3
2242
71.4

29 614
8.9
2468
75.5

20.9

17.2

77.1
83.8
1.3
171.9

75.4
81.6
1.5
271.2

159.7

179.2

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

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).

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

389

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 stewards 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 Spanish MoHs 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
6

Except the Basque Country and Navarra, who have enjoyed their own revenue-raising power as historical
rights set out in the 1978 Spanish Constitution.
7
These are generally not utilized because raising taxes is an unpopular policy.
8
Approved by the National Council for Financial and Fiscal Policy (Act 21/2001, 27 December 2001). A
new agreement is currently undergoing revision for 2009.
9
With the new agreement, the ACs are required de jure to allocate a minimum amount of their expenditure
to health care services. This amount, however, is easily met as it is relatively low compared to general
health expenditures.
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V. BANKAUSKAITE AND C. M. NOVINSKEY

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 WHOs 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 NHSs 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 commissionshave been
patchy and ad hoc since its establishment, and agreements and decisions have not
10

Law 29/2006, on the 26 of July.

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STEWARDSHIP OF THE SPANISH NHS

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 governments 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
MoHs 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 the MoH
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-functions 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 the MoHs 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 the MoH (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
11

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

12

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V. BANKAUSKAITE AND C. M. NOVINSKEY

attainment of both health and NHS goals. Despite some variability in design and
content, the various AC health plans and the MoHs 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 the WHO 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 Patients 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 stewards realm impact on health and, thus, it is wiseand
necessary in a decentralized systemfor 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
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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 decisionmaking 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
13

El Consejo de Poltica Fiscal y Financiera.

Article 13 of the Prevention of Labor Risk Law (31/1995, 8 November).

14

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V. BANKAUSKAITE AND C. M. NOVINSKEY

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 MoHs
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 patients 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 the MoH 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
15

Ley 41/2002, de 14 de noviembre, basica reguladora de la autonoma del paciente y de derechos y

obligaciones en materia de informacion o documentacion clnica. BOE n.274 de 15/11/2002.
16
This 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).
The MoH, 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 interoperability 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
17
Including the 10 ACs under pre-2002 management of INSALUD (Aragon, Asturias, the Balearic Islands,
Cantabria, Castile La Mancha, Castile and Leon, Extremadura, Madrid, Murcia, and La Rioja) and the
Canary Islands.
18
The 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.
19

Consejo de Salud.

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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, creating major difficulties for the MoH
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 the MoH 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 MoHs 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 issuessuch as
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V. BANKAUSKAITE AND C. M. NOVINSKEY

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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