From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

Spain’s response to the coronavirus pandemic – the August update (2020)

Kristin Edquist and Mario Martínez Jiménez

Since mid-May, Spain’s central government continued its de-escalation phase, established ‘new normal’ (nueva normalidad) legal requirements on 9 June, lifted the state of emergency on 21 June, held a national memorial service presided over by King Felipe VI (16 July), and faced a dramatic increase in positive test results, currently around 5.5% – up from ~1% in early June. The ‘new normal’, inscribed in national law on 9 June, mandates the use of masks in public venues and transport, including outdoor venues (except for sports participants). It also requires institutions and organisations, such as places of employment, to provide water, soap or sanitizer, and ventilation, as well as additional requirements for health services, educational facilities, commercial venues, lodging for tourists, and sporting and cultural events. Air travelers from abroad must submit ‘Passenger Location Cards’ identifying their destinations and COVID-19 status; undergo temperature checks, and visual checks. These requirements complement those of Autonomous Communities (ACs). Non-compliance penalties vary. Several ACs, including Galicia, Cantabria, the Basque Country, and Catalonia, skipped the last phase of de-escalation and moved directly to the “new normal” procedures. Schools at all levels remain closed.

The new normal also entails improved early virus-detection capabilities. As of mid-May, ACs controlled COVID-19 testing, even within private laboratories. Prescriptions are required for testing, which must be paid out of pocket (sometimes costing 95 euros). Waits can vary from 24 hours to five days. Testing capacity dropped sharply by early July, but capacity improved: by 30 July, the national Health Ministry reported 4.65M tests—a 7% increase in one week. Spain conducted ~70 tests per 10,000 inhabitants weekly as of early August.

Late July and early August have seen an increase in 14-day COVID-19 case notification rates, with increases varying by age group. Numbers are flat for 65-79 and 80+ year-olds, but are up by nearly 100/100,000 in people 15-24 years old (ECDC numbers).  The World Health Organization reports slightly lower numbers, but showed a 76% increase in confirmed cases during the third week of July. Death rates are much lower than in March but have increased in the last few weeks: 17 deaths reported 20 July, and 45 deaths on 27 July.  These rates scared off other countries: the UK enforced a 14-day ban on travelers from Spain, and required a 14-day quarantine for travelers (returning) from Spain. Germany advised travelers to avoid non-essential travel to Aragon, Navarra and Catalonia.

Concerns remain about weaknesses in Spain’s contact-tracing abilities. A National Epidemiological Survey has put pressure on ACs’ contact-tracing efforts; for example, by noting that Catalonia averaged two contacts and one new infection per reported case of COVID-19 (the lowest rates in the country). Catalonia’s Health Department reported in mid-July that it would increase its contact tracers from 300 to 900 persons, though it scaled back on the number of tracing-support personnel in call centres after complaints that the workers were ill-trained.

Conditions in homes for the elderly remain a national concern.  Infection rates are level and much lower than in March for ages 65-79 and 80+, but the national Health Ministry has been quite silent on this issue, saying that data on deaths among persons in elderly homes is poor.  It blames regional governments for the lack of data. Part of the problem lies in the very different market for nursing homes, which is dominated by private owners and managers, and lacks uniform reporting requirements, as well as other official standards like staff composition and staff/resident ratios. Occupants can be either publicly or privately funded. The Ministry of Science implicitly criticized the Ministry of Health in a recent report, in which it had to refer to outside data in order to determine rates of death and infection in the homes.

In these areas, the government remains under pressure, and even the more-centrist Popular Party has announced that it is watching the government for over-reach in terms of any upcoming new restrictions on personal movement; the PP says it prioritises citizens’ lives, but is also concerned about the national economy. Tensions between national and AC responses to the pandemic likely will remain long into the future.

Spain’s response to the coronavirus pandemic – Update (May 2020)

Kristin Edquist and Mario Martínez Jiménez

Despite the national government’s weak position as a minority coalition, it has succeeded in continually prolonging Spain’s state of emergency and nation-wide quarantine; the current extension ends May 24. In fact, the national government’s response has reinforced its power relative to Spain’s 17 Autonomous Communities (autonomies). It has used this power to enforce a particularly stringent quarantine, involving closure of land borders, airport and port border restrictions (currently extended to May 15), and school closures nationwide. Pressure from citizens and government officials has effected some changes: as of April 27, children under 14 have outdoor time for one hour within one kilometre of home. And by May 4, after 48 days of near-total confinement, adult residents could walk or otherwise exercise outdoors, in schedules by age. Yet the meagre concessions illustrate the strength of the government’s response, though fissures in support are re-emerging.

The response has succeeded in several respects. As of May 11, the monthly infection rate had decreased from 12/100K to 1.9/100K. From May 4, patient admissions for ICU treatment were at their lowest (21) since the state of emergency declaration; ten autonomous regions reported no seriously ill patients. Madrid and Catalonia hospitals maintain 150% ICU bed capacity. Elsewhere, ICU bed numbers have tripled. Autonomous regions also have acquired extensive testing capacity and pricing controls.

State support for individuals or temporary workers continues. Additions include temporary subsidies for household employees, extension of temporary university teaching and research contracts, and provision of housing programs for victims of gender violence, homeless people, and other vulnerable populations. Legislation approved April 21 adopted several fiscal measures to ensure EUR 1.1B liquidity. Self-employed workers can adjust personal income tax and VAT payments to real income, and corporations can adjust tax payment to estimated 2020 revenues. In line with the EU, Spain has reduced VAT to 0% on domestic sales of nationally produced medical equipment.

Not surprisingly, the government has plans to lift lockdown measures, but it commenced the plan on the same day that the Health Ministry’s serological survey, deemed necessary to gauge readiness for lifting the lockdown, began. The survey will last for eight weeks, but the government has begun the four-phase plan for autonomies, ‘co-governing’ with the national government (which it claims will boost consensus and coordination), to relax quarantine measures:

May 4 ‘Phase Zero’ begins: limited outdoor exercise, one-on-one training for professional athletes, hardware store and hair salon re-openings, and restaurant re-openings for takeaway only.

May 10 ‘Phase One’ allows intra-autonomy travel, 10-person gatherings, and sidewalk cafe and religious site usage at 30% capacity. Public transport capacity increased to 80% with masks obligatory.

At least two weeks later ‘Phase Two’: reopening of shopping areas, bars and restaurants with inside seating, cinemas, theatres, etc. (30% capacity). Visits to disabled persons in homes, but not to the elderly, permitted. Schooling provided for children under age six if needed for parental employment, and for students to complete university entrance exams.

‘Phase Three’, likely mid-June, will see senior home visitations (under conditions to be determined), open bars, cinemas and theatres (50% capacity), and shopping inside (50% capacity with social distancing).

End of June ‘Phase Four’: lifting domestic social and economic restrictions. Border restrictions persist until the state of emergency is lifted.

Transition into each subsequent phase theoretically depends on healthcare capacity (primary care, hospitals, ICU beds), testing and infection rates, level of compliance with protection measures, and a guaranteed supply of 1.5-2 ICU beds and 37-40 beds for acute patients, for every 10,000 inhabitants. Given the peremptory start of Phase Zero before the serological survey’s completion, trust in these criteria may be low.

Assessment

The national coalition government’s response, led by the Socialists (PSOE) and junior partner Unidas Podemos, has been criticised vehemently by the centre-right People’s Party, which labelled Prime Minister Sánchez a ‘liar’, and far-right Vox — the third-biggest party in Congress — which demanded Sánchez’s resignation and formation of a government of national unity. Regional premiers have voiced opposition to state of emergency extensions, to little avail.

Meanwhile, a key government ally the Basque Nationalist Party (PNV) criticised ‘co-governing’ arrangements with the regions, and the Catalan government has raised concerns about the central government’s essentially seizing control of each autonomy, de-escalation of quarantine measures without knowing the epidemic’s national scope, suspension of transparency legislation, and silence on government procurement actions.

Despite the government’s success in prolonging the lockdown, political fissures are re-emerging and may be deepening. The health crisis and ensuing economic reckoning will pose formidable challenges for the current government and perhaps for Spain’s national unity. If infection numbers resurge, it may be difficult for the government to reimpose the same drastic measures, and it is unclear how willing will be the regions to abide by continued central control.

Spain’s response to the coronavirus pandemic – Original post (April 2020)

Kristin Edquist, Associate Professor of Political Science, International Affairs, and Public Administration, Eastern Washington University (USA)

and Mario Martínez Jiménez, PhD Candidate, Health Economics, Lancaster University, UK

Spain’s strengths and challenges in responding to the COVID-19 pandemic reflect larger governmental strengths and challenges. Like most European Union member states, Spain has a public National Health System (est. 1986), providing universal coverage free of charge except for prescribed medicines. Supplemental private insurance is purchased by approximately 15% of the population, often for specialty care. Care for the elderly (65+) operates differently, with private homes (65%) outpacing public (35%) and low bed provision by EU standards (4 per 100), in part because elderly persons often live with extended families. Spain’s healthcare is highly developed and WHO rates its primary care among the best in the world.

Yet political devolution and severe budget cuts after the 2008 financial crisis have weakened the State’s healthcare capacities. Since 2002, all healthcare competences lie with the 17 Autonomous Communities (ACs). The national Health Ministry retains regulatory authority only. Meanwhile, Spain’s healthcare budget in 2017 resembled the 2009 budget. Madrid and Catalunya, since hit hard by COVID-19, saw particularly deep cuts.

Spain’s COVID-19 response has been increasingly drastic but primarily reactive rather than anticipatory. The State has adopted wide-ranging policies, including disease-mitigation and -suppression measures, emergency economic aid and financial relief, and disease-prevention research. But its primary care system was not initially mobilized, its mandates confused persons who fled affected regions but took the virus with them, it permitted expensive inter-regional competition for resources, and hospitals in some regions have been overloaded and frontline healthcare workers left under-protected and forced to make excruciating decisions about who receives lifesaving care.

Timeline: On 31 January, Spain confirmed its first case of COVID-19, in the Canary Islands. On 12 February, the Ministry of Health recommended nation-wide infection control measures for persons attending public events. On 9 March, in Madrid, Vitoria, and Labastida, the State suspended enclosed-space activities of over 1000 people, closed all schools, and encouraged employers to establish flexible working conditions.

Spain’s first mainland case of the virus, reported on 25 February, involved an Italian citizen travelling to Catalunya. The State prohibited direct flights from Italy on 10 March. On 12 March, the NHS implemented national social distancing measures, including home care for the elderly. Reported COVID-19 cases reached 4,209 on 13 March. On 14 March, Spain commenced a National State of Emergency (extended to 11 April) mandating self-isolation, the closure of schools, bars, restaurants, shops, and all but essential travel and public services (sanitary, food, and meal-delivery). Yet the declaration was made at the weekend and created some confusion: Many people in the hardest-hit areas scattered home, likely encouraging the virus’s spread. A lack of coordinated scientific advice may have contributed to the confusion: While experts had been advising the government, it only established the Health Alert and Emergency Coordination Centre on 21 March. On 16 March, Spain re-instituted border controls on all land borders. On 28 March, it restricted all non-essential economic activities from 30 March to 9 April.

Healthcare response: Like most countries, Spain has lacked the capacity to conduct widespread tests to detect the virus (SARS-CoV-2) or disease (COVID-19), and has faced challenges finding tests that are quick and/or reliable. The State purchased 5.5 million testing kits from China’s central government on 25 March. The same day, 640,000 rapid testing kits purchased through a different contract arrived from China and South Korea. The failure of 9,000 of these tests was reported widely.

Another challenge has been the shortage of personal protective equipment (PPE), such as masks, gowns, and gloves. While the State of Emergency allows the State to centralize purchasing processes—normally decentralized to the 17 ACs—some ACs balked at centralization, and the State relented. The central government has purchased and distributed some PPE, yet hospitals report shortages.

Related to the PPE shortage is the high rate of infection among healthcare workers. By late March, 9,444 workers were reported infected, at a rate of 12% according to the government. Yet it is unclear how many nurses or other professionals had been quarantined, or what these numbers mean because of the testing gap. It is safe to say that the State is facing pressures to respond. It has attempted to meet the dramatic increase in demand for healthcare by recruiting immigrants with medical expertise, extending the contracts of medical residents, and recruiting medical and nursing students in their final years, to supplement Spain’s 147,000 doctors and 182,000 other healthcare professionals.

The high rates of infection in older populations have also put pressure on the government. Spain has an ageing population, and enjoys one of the longest life expectancies in the world. In the case of COVID-19, the integration of the elderly into Spanish homes unfortunately may explain the high death rates amongst the elderly. Still, in 2009, over 90,000 people awaited public nursing home beds. Such patients often must occupy beds in public hospitals. Regional hospital bed shortages, combined with the late institutionalization of expert government advice, may help explain the shocking news on 23 March that special army units cleaning residential homes had found the corpses of elderly persons, apparently abandoned. The State has assumed control of private residences.

According to Spain’s Health Ministry, its main policy objective in the outbreak is to avoid the collapse of hospitals through overload of available intensive care beds. Unfortunately, some regions may be reaching overload. Spain’s normal ICU bed allocation is 4,627 in public hospitals; total ICU beds in use on 5 April equaled 6,861. Madrid (autonomous community) accounted for 1,499 of these ICU cases, Catalunya, 2,249. Meanwhile, Andalusia accounted for 474 ICU cases. Madrid reported the highest death rate of 74 out of 100,000. Catalunya reported 34, and Andalusia 6 out of 100,000.

The State has responded by purchasing ventilators from China and negotiating ventilators from Spanish companies. On 3 April, SEAT contracted to manufacture 300 per day. Madrid’s Hersill has pledged to double its ventilator output to 100/day. The State also has allocated €2800 million for health services to all regions and created a €1,000 million fund for priority interventions.

Prevention: The testing gap contributes to the State’s preventive abilities through detection and monitoring. In attempts to address this problem, on 19 March, the government released a €24 million Call for Proposals of research projects on SARS-COV-2 and COVID-19. Successful proposals must accommodate immediate NHS implementation. It also has approved 13 clinical drug trials, including trials of therapeutic approaches combining antivirals with hyperimmunity blockers, and the use of recovered patients’ blood plasma.

Evaluation: Spain has high infection and death rates due to COVID-19, and has reached over 130,000 cases. While Spain may be ‘ahead’ of other states such as the US and UK on the epidemiological curve, and while testing worldwide is not sufficient, it does appear that China and South Korea have seen levelling in the number of deaths per day. Meanwhile, Spain’s death rate curve is as steep as China’s curve during its first 10 days of outbreak, yet Spain is in its 30^th day since outbreak (European CDC numbers). Spain is a very different country from China, but it had the advantage of foreknowledge. Decentralized states with budget cuts can take heed.

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