The need for an independent evaluation of the COVID-19 response in Spain
Authors: Alberto García-Basteiro, Carlos Alvarez-Dardet, Alex Arenas, Rafael Bengoa, Carme Borrell, Margarita Del Val, Manuel Franco, Montse Gea-Sánchez, Juan Jesús Gestal Otero, Beatriz González López Valcárcel, Ildefonso Hernández, Joan Carles March, José M Martin-Moreno, Clara Menéndez, Sergio Minué, Carles Muntaner, Miquel Porta, Daniel Prieto-Alhambra, Carmen Vives-Cases, Helena Legido-Quigley
Journal: The Lancet (2020)

Spain has been hit hard by COVID-19, with more than 300 000 cases, 28 498 confirmed deaths,1Ministerio de SanidadActualización no 177. Enfermedad por el coronavirus (COVID-19).https://www.mscbs.gob.es/en/profesionales/saludPublica/ccayes/alertasActual/nCov-China/documentos/Actualizacion_177_COVID-19.pdfDate: Aug 4, 2020Date accessed: August 4, 2020Google Scholar and around 44 000 excess deaths, as of Aug 4, 2020.2Instituto de Salud Carlos IIIVigilancia de los excesos de mortalidad por todas las causas: MoMo.https://www.isciii.es/QueHacemos/Servicios/VigilanciaSaludPublicaRENAVE/EnfermedadesTransmisibles/MoMo/Documents/informesMoMo2020/MoMo_Situacion%20a%2019%20de%20julio_CNE.pdfDate: July 19, 2020Date accessed: July 24, 2020Google Scholar More than 50 000 health workers have been infected, and nearly 20 000 deaths were in nursing homes.3Ministerio de SanidadActualización no. 169: enfermedad por el coronavirus (COVID-19).https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov-China/documentos/Actualizacion_169_COVID-19.pdfDate: July 23, 2020Date accessed: July 24, 2020Google Scholar With a population of 47 million, these data place Spain among the worst affected countries. Spain is also reported to have one of the best performing health systems in the world4Fullman N Yearwood J Abay SM et al.Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016.Lancet. 2018; 391: 2236-2271Summary Full Text Full Text PDF PubMed Scopus (626) Google Scholar and ranks 15th in the Global Health Security index.5Nuclear Threat InitiativeJohns Hopkins Bloomberg School of Public HealthGlobal Health Security index: building collective action and accountability.https://www.ghsindex.org/wp-content/uploads/2019/10/2019-Global-Health-Security-Index.pdfDate: October, 2019Date accessed: July 21, 2020Google Scholar So how is it possible that Spain now finds itself in this position? Potential explanations point to a lack of pandemic preparedness (ie, 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. These problems were exacerbated by the effects of a decade of austerity that had depleted the health workforce and reduced public health and health system capacities. A comprehensive evaluation of the health and social care systems is now needed to prepare the country for further waves of COVID-19 or future pandemics, identifying weaknesses and strengths, and lessons learnt. We are calling for an independent and impartial evaluation by a panel of international and national experts, focusing on the activities of the Central Government and of the governments of the 17 autonomous communities. This evaluation must include three areas: governance and decision making, scientific and technical advice, and operational capacity. Moreover, the social and economic circumstances that have contributed to making Spain more vulnerable, including rising inequalities, must be considered. Specific concerns include public health functions, leadership and governance, financing, health and social workforce, health information systems, service delivery, access to diagnosis and treatment, the role of scientific research, and the experience and values of individuals, communities, and vulnerable groups. This evaluation should not be conceived as an instrument for apportioning blame. Rather, it should identify areas where public health and the health and social care system need to be improved. Although this type of evaluation is not usual in Spain, several institutions and countries, such as WHO6WHOIndependent evaluation of global COVID-19 response announced.https://www.who.int/news-room/detail/09-07-2020-independent-evaluation-of-global-covid-19-response-announcedDate: July 9, 2020Date accessed: July 21, 2020Google Scholar and Sweden,7Swedish Ministry of Health and Social AffairsMats Melin to chair COVID-19 inquiry in Sweden.https://www.government.se/press-releases/2020/06/mats-melin-to-chair-covid-19-inquiry-in-swedenDate: July 1, 2020Date accessed: July 24, 2020Google Scholar have accepted the need for such a review as a means towards learning from the past and preparing for the future. We encourage the Spanish Government to consider this evaluation as an opportunity that could lead to better pandemic preparedness, preventing premature deaths and building a resilient health system, with scientific evidence at its core. AA has advised the Spanish and Catalan Governments. BGLV is a member of the multidisciplinary working group on COVID-19 for the Ministry of Science and Innovation of Spain, a member of the scientific committee on COVID-19 for the Government of the Canary Islands, Spain, and a member of the COVID-19 group of the Medical Council of Spain. IH has assessed two regional Spanish Goverments on COVID-19. All other authors declare no competing interests.