Analysis of the Spanish Health System that has just been admitted to the ICU during the pandemic (COVID-19)

If an intensivist is capable of doing an analysis of the situation for something, it is because our training has taught us to carry out multiple procedures (general management, financial, personal and care) both outside and inside the ICUs. The intensivist has been (not so long ago) Hospital manager, manager of large units (Emergency and Critical Care as in Andalusia), manager of his own ICU, management of critical patients wherever they are. For a scenario like the ICU, between 5% (Spain) and 10% (Europe) of hospital beds, these consume between 20 and 30% of the resources for acute patient care, which in the European Union represents an annual cost of more than € 90,000 million.

Year 2020. The COVID-19 pandemic

It has always been cited by our health policy politicians that Spain is one of the best (if not the best) health system in the world. That has come as a result of some sources that cite Spain as one of the three leading countries in effectiveness in relation to spending.

The Bloomberg report [1] measures the efficiency of health systems through life expectancy, health spending per capita, and the relative weight of health spending over GDP. It analyzes the parameters in 56 economies where life expectancy is more than 70 years, have a per capita income of more than 5,000 dollars per year and a minimum population of 5 million inhabitants, determining which are the most and least efficient in this regard . And in its latest edition, Hong Kong lead the ranking, with 87.3 points and Singapore, with 85.6

And in third place, Spain has a total score of 69.3, which is combined with its life expectancy, 82.8 years, a health expenditure of 9.2% compared to GDP and $ 2,354 (about 2,000 euros) per person and year in absolute terms. This allows Spain to also be the most efficient healthcare system in Europe – something it has been achieving since 2013 -, surpassing Italy (4th position globally) and countries such as Norway, Switzerland or Ireland, although all of them were already in the Top10.

What does “Effectiveness” mean

Clinical effectiveness is often defined as “the application of the best knowledge – derived from research – clinical experience and patient preferences to achieve optimal processes and results in health care.” But effectiveness is a term of greater scope than effectiveness [2], since it expresses the measure of the impact that a given procedure has on the health of the population; therefore, it addresses the level with which tests, procedures, treatments and services are provided and the degree to which patient care is coordinated between physicians, institutions, and time.

Efficiency means achieving a specific result from a minimum of resources or obtaining the maximum benefit from limited resources.


This is the million euro question.

It really is NOT, because in cases like the COVID-19 pandemic, it has not been able to correlate efficiency with the available resources, on the other hand, deficit in everything.

We must clearly distinguish what we are talking about, because the tendency to lie is typical of the abuse of words by politicians and that generate confusion.


The Spanish Ministry of Health, Consumption and Social Welfare published statistics on specialized care health centers in 2016. The number of public beds belonging to the national health system (SNS) is 454 hospitals with a total of 122,047 beds [3]. There are 310 private centers with 31,333 beds. In a crisis situation, that would mean a total of 764 hospitals with 153,380 beds, which means 326 beds / 100,000 inhabitants (100K). Compared to the rest of Europe (27 countries, since 2020), Spain had 215 beds less than the 541.43 beds / 100K registered by the European average [4]. Germany is the country that has the most total beds compared to its population, which registers 800 beds for every 100K.

The total number of critical care beds in Spain identified in a registry between 2010-2011 was 5,596 in which, excluding beds for neonates, pediatrics and stroke units, they were 4,738, which for a population census (1 of April 2011) of 46,148,605 inhabitants, generated a resource of 10.3 ICU beds per 100K inhabitants [5]. However, the number of ICU beds in Spain reported by SEMICYUC to date is 3,598 (2019) compared to 38 14 beds according to the registry of the Ministry of Health of Spain in 20 17 [4], which means a proportion 7.8-8.2 beds / 100K inhabitants. Once the beds in private centers have been recovered by the Ministry (more than 730 beds), this level rises to 9.3 beds / 100 K. [4]

If we take a look at the previous graph, our country in number of public beds (297.28 per 100,000 inhabitants) is much lower than the average for the European Union, which stands at 541.3 beds. We are talking about less than 215 beds per 100,000 inhabitants. Surrounding countries such as Portugal (339), France (598) or Italy (318) surpass us. But curiously, eastern countries such as Bulgaria (745), Hungary (701), Romania (689) practically double us in resources, yet they do not beat us in life expectancy. The point is that we Spaniards have fewer resources but we are better at prevention and that leads to the fundamental question, doctors and nurses are the best in Europe, although without resources. THE SAME HAPPENS WITH THE ICU BEDS.

Okay, but this does not mean that in a crisis like the one we suffered, even if we are better health workers, we cannot bear the emergency of a chaotic situation IN A PANDEMIC, because we have a lack of hospital and ICU beds, as well as other resources.

It is a problem that has been added since the beginning of the economic crisis in 2007. The health cuts began as the deficit and the fall in gross domestic product were pressing, millions of jobs were lost and there was no way to maintain spending, for therefore the number of beds was cut as well as the number of staff. The crisis fell, of course, in the Health, which has been kept afloat by its health workers, not by the politicians on duty from different parties, because the cuts began and let’s not forget, with the Zapatero government in 2008 before and they continued with those of Rajoy (2011) during crisis and likewise the current ones that have not invested in Health. Why? Simply because the system in spite of everything was maintained and with a high level of efficiency in part by:

Control of the salaries of doctors and nurses and other groups of public employees (the worst in the Eurozone), but very effective.
No or almost no resource management. The devices age, the hospitals have not been renovated or as little as possible.
Why are we going to change things, if in the end the system continues and works (that must be the idea of ​​the politicians)

Answer: During the 2007 crisis, Zapatero cut resources and from 2011 to 2014, Rajoy not only maintained the cuts but also cut wages and pay. Careers cut off. The only objective is to maintain the rest of the budgetary expenses to reduce the deficit and create employment. Jobs were created, but health systems were cut back. All because it works, although it has been thanks to the professionalism of health workers in gene


What about the health personnel now? Hospitals are not built or those that build do not add surplus beds. The losers of the health situation are the population, who blame it on the system. But nobody talks about health workers, those who have had to work double shifts, fatigued and against the current of the poor health situation and also infected (the highest rate of health workers in the world) and a mortality of almost 75 health caregivers.

Do we have enough doctors and nurses?

As the newspaper El Confidencial says: No, Spanish healthcare is not the best in the world [6]. Nor from Europe, and there is even a reasonable doubt that it is not even the best in the Iberian Peninsula. In terms of health, we are a country from the heap – yes, from the top of the heap – where people live for many years, do many transplants and, as Carlos Sánchez explained in these same pages, doctors earn considerably less than their European counterparts

Why? Because doctors, nurses and health workers are the most devoted in the world. Indeed heroic because of the few resources we have.

The World Economic Forum study, for example, measured ‘healthy life expectancy’, but not the quality of health care, which is ordinary. We are efficient but not thanks to politicians but to the efforts of health workers, who risk their lives in these conditions.

What has made the pandemic discover our inefficiency and our shortcomings?

This misfortune had to happen to take out our hardships. Politicians know them and knew them, but they let it go. A denial is better than an acknowledgment of our weaknesses. That is the political cost that no one wants.

In return, nothing has been done either. It is better to deny the evidence and deny the failure that someone will always have to do it later, but they will no longer be themselves.

What have been our ailments?


Our country is definitely in the ICU, in a comatose state, which is not solved until there is an investment as did the other countries that are ahead of us in resources, even those countries that could be economically worse off than us.

We have bragged about being the best and we really are the bottom heap, but yes, we are better in efficiency when there are no resources. NOW IF I CAN IMAGINE HOW WE WOULD BE, IF WE HAD THE SAME CONDITIONS AS GERMANY


PERSONNEL: Of course, it only passes as an incentive to health personnel, who are those who have been permanently in the eye of the cyclone. One thing is that they tell them that they are heroes and another is that they do not want to be heroes, but recognized professionals with professional careers and emoluments in line with those of the rest of the countries of the European Union. The salary of a doctor is still ridiculous compared to Germany, France, Nordic countries, Switzerland, the Netherlands, etc. Ridiculous is little. We are talking about highly qualified professionals who have never been recognized in this country (it seems that anyone today can be a doctor using Google as their textbook). Professionals with 6 years of career, between 4 to 5 years of very hard specialties and a complete dedication that sometimes involves many personal sacrifices with very tough conditions and long hours of work. Not rewarded or professionally.

Is that really what we want from this country? Any other profession is financially advantageous to them, but nobody thinks about it until they fall ill, that’s when we think about its value. But the next day once we are well, we forget. It’s all too hypocritical.

Hospital beds. We must increase our hospital beds, but not by building them in Fairgrounds or Sports Centers. They must be built in those deficit areas and get at least 200 beds for every 100,000 inhabitants to be within the European average.

ICU beds. Our resources are ridiculous, taking into account that we have (I am talking about the public) of 7.8 beds per 100 thousand inhabitants, while we need 14 beds of the European average (I am not talking about having 33 like Germany or the USA). Hospitals at this time and before the pandemic were already deficient with attendance levels of 80-90%, where the struggle with the last ICU bed had been evident for more than 20 years. We have had to remove patients sometimes still serious, to put others more serious and even in general wards because not all centers have the intermediate ICU (Step-down) where those patients pass for intensive care with less invasion and support before to go to recover to a normal room. Again and it is not new, I do not remember how many times we discussed these problems in the guards that never had solutions, because the managers do not care, since they have not come to see these problems and some heads of service did not want to be at bad with the managements and like this every year one and another.

Renovation of the technology park. Yes, the truth is that it is not fair that someone with a lot of money comes to provide technology based on donations, when the same public system does not. Those donations are appreciated and more now, but we are a country with a lot of “spending on politics” and “zero on health.” It is unseemly, it is regrettable, that money only serves to support so many politicians who have demonstrated their inefficiency. In Italy they have recently had the decorum to acknowledge it and there are plans to reduce them. Money has to come out to achieve these goals. In Spain this problem is not recognized by our politicians and less now where there is a macroeconomy dedicated to the politician of the future.

Within these shortcomings, perhaps at another time we should talk about the absence of basic resources during the pandemic, such as the lack of personal protective equipment (including PPE and masks) where it has been the last straw, making our professionals not they just could not protect themselves, but have paid for it with their own lives (more than 75 professionals have died). This lack of action (due to the denial of the epidemic at the beginning) has resulted in the disastrous action of the Government in its containment plan that lasted so little as to generate the state of alarm so quickly when the WHO had already declared the Pandemic two days before.WHO, in order to achieve the public health goals of each phase, the objectives and specific measures to be adopted by WHO and those recommended to national authorities are divided into five categories:

  1. Planning and coordination,
  2. Monitoring and evaluation of the situation,
  3. Prevention and containment,
  4. Health system response and
  5. Communications.

In Spain, the prevention plan did not work (it practically fell on them), the containment plan lasted just enough to go directly to the state of emergency.

Brief memory of History.
The SARS (Severe Acute Respiratory Syndrome) epidemic due to the coronavirus appeared in 2002, affecting mainly China and part of Southeast Asia, as well as the United States and Canada.

But in Spain we had a PLAN since 2003.
How was the National Plan for a Pandemic developed?

The elaboration of this exhaustive Plan began in 2003, when the WHO issued recommendations to all countries to face an influenza pandemic and the ‘National Executive Committee for the prevention, control and monitoring of the epidemiological evolution of the virus was created. of the flu ‘, elaborating a’ National Plan against a possible flu pandemic ‘.

In March 2004, the European Commission also produced a working document called ‘Community Planning for Flu Pandemic Preparedness and Response’. Then the WHO presented another plan on a global scale in 2005, which helped the Spanish government update the previous one. When this 2005 National Plan was developed, it was recognized that

“Pandemics behave in unpredictable ways.” The cases occurred “very quickly and increase exponentially in a very short time.”

During this initial epidemic and subsequent pandemic, the countries that acted swiftly had all the necessary action steps at their fingertips.

What has happened to not recognize this problem that was seen coming. Our country was totally caught off guard, with no ideas and how to handle it. Neither protocols nor the Plan that already existed removed it.
Those responsible have not been at the heights demanded of them. There was never a committee of experts, although as I have always said that being an expert in this crisis is nobody, unless you have experienced it in person before it happens.

You can already have a master’s degree in public health, but if you have not experienced a situation like the current one previously, you are not an expert even if you have a degree.

My next article will be about “Who is and is not an expert on issues such as the current pandemic.” Or because Dr Anthony Fauci, despite being ousted by the President of the United States, is one of the greatest authorities in the world.

China is together with the US, they are the countries with the most knowledge and experts in Pandemics in the world. But China was exemplary, its actions (at first delayed) but 15 days later it already had the coronavirus genome and total oriental discipline, it has made the containment phases safe and did not need any state of alarm in the country. Today everyone knows that China is the safest country right now and it has been since last July. Its control measures, containment, response, trackers and decisions have been the B side of how to act. Let’s stop the nonsense about China being a communist country and stupid aspects that are totally unfounded. The Chinese are experts in pandemics and disciplined citizens who look out for the general interest.

In the US there are many experts, but greater deniers, including representatives of the people. In any case, despite the tragic numbers of cases and deaths, their mortality is lower than in Europe and there has not been a catastrophe of resources, because they have always had more resources than in Europe.

The author has no conflict of interest in this publication


1.- informe Bloomberg

2.- Lam Díaz Rosa María, Hernández Ramírez Porfirio. Los términos: eficiencia, eficacia y efectividad ¿son sinónimos en el área de la salud?. Rev Cubana Hematol Inmunol Hemoter [Internet]. 2008 Ago [citado 2020 Oct 11] ; 24( 2 ). Disponible en:

3.-Estadística de Centros Sanitarios de Atención Especializada. Ministerio de Sanidad, Consumo y Bienestar Social. 2016. (online since May 1st, 2020).

4.- Hospital beds provide information on health care capacities. European Union. Eurostat. 2020. (available on line since May 1st, 2020).

5.- Recursos estructurales de los Servicios de Medicina Intensiva en España. Martin MC, León C, Cuñat J, del Nogal F. Med Intensiva. 2013; 37(7): 443-451.

6.-Elconfidencial. Si España fuera la mejor sanidad del mundo no necesitaríamos héroes contra el Covid-19.


Herrero S. “Análisis de la Sanidad que acaba de ingresar   en la UCI (COVID-19)”. The Journal of Pearls in Critical Care. Noviembre 2020 Vol. 71

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Former Head of Department Cardiac Intensive Care
The Jilin Heart Hospital
5558 Jingyue Street
Changchun, Jilin Province
130117 China

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