At the Spanish Society of Public Health and Health Administration (SESPAS) we created a working group of 28 experts to propose the creation and development of a State Public Health Agency (AESP) to prepare us to protect the health of our population in the face of the current pandemic, future pandemics and current health challenges. With this objective in mind, we are publishing an article today in the journal Gaceta Sanitaria in which we describe in detail the needs, challenges and functions of this Agency, which we summarise below.

Before justifying the need for this Agency, it is important to define the term "public health". Public health is the set of activities aimed at preventing disease and protecting, promoting and restoring the health of populations through actions involving different institutions (municipal, territorial, state and international) and sectors (health, education, transport, urban planning, etc.).

Why do we need a Public Health Agency?

The need for a Public Health Agency, although it already existed before, has become particularly clear in the context of the pandemic, which is undoubtedly the most important collective health problem of the last century, with significant social and economic consequences: more than 90,000 people have died in Spain as a result of covid-19 (5.5 million worldwide), and more than 9 million had been infected by January 2022.

It is necessary to have a powerful and well-articulated institution that supports measures to protect the health of our population, based on the best available scientific evidence, and that clearly communicates the balance of risks and benefits of these measures

Given that the virus knows no borders and that the likelihood of infection and serious illness depends on multiple circumstances related to how people live, work and socialise, it is easy to understand why wide-ranging institutions are needed to protect the population. But beyond this, it is essential to recognise the role that the environmental, social and economic environment plays in people's health: for example, air pollution and the respiratory diseases that result from it, or the mental health problems that are associated with work, economic or even socially limiting circumstances.

It is therefore necessary, now more than ever, to have a powerful and well-articulated institution that supports measures that can protect the health of our population, based on the best scientific evidence available. The public deserves an institution that also clearly communicates the balance of risks and benefits of these measures.

Spain's situation and challenges

In Spain, public health has developed under chronic underfunding, accentuated during the cuts that occurred during the Great Recession. In 2019, public health spending in nominal terms (i.e. excluding inflation) was lower than in 2007. In relative terms, the weight of public health has also declined in recent years: from just 1.6% of total public health expenditure in 2009, by 2019 the share had fallen to 1%.

High investment in health technology, unaccompanied by a process of analysis and identification of needs, lacking clear and transparent prioritisation mechanisms, and lacking a clear focus on disease prevention and health protection, has reinforced a welfarist, inefficient and indebted health system.

The current situation, coupled with the more immediate challenges, such as those arising from the climate crisis, calls for an immediate shift away from a welfarist and trenchant model of preventive and health-generating service provision

The current situation, coupled with more immediate challenges, such as those arising from the climate crisis, calls for the immediate establishment of a preventative and health-generating service delivery model, rather than one that is welfarist and entrenched, which must go hand in hand with actions from different sectors, drawing a livable and equitable horizon for all people without exception. At the present time, we need the public agenda to prioritise people's health and the development of healthy communities that maintain a sustainable relationship with the planet and its ecosystems.

What should the State Public Health Agency look like?

We need an adequately resourced institution that can draw on the enormous capacities of professionals from a wide range of disciplines already working in various Spanish institutions. To be up to the challenges it faces, the future agency should have a sufficient budget to be able to carry out, with the appropriate staff, the functions described below.

We propose that this institution should take the form of a state agency, independent of political power and with a high technical capacity, enabling it to build a reputation for excellence. We envisage it as an institution that, on the basis of the best and most complete scientific knowledge, and free from conflicts of interest of various kinds, would serve to advise decision-makers on how to protect, promote and improve the health of the population. An institution of this nature can contribute, together with some other existing institutions (for example, the Independent Authority for Fiscal Responsibility, AIReF), to setting an example in the process of modernising the country's institutional structures, where good governance and good public management are hallmarks.

The new agency will have to address, in addition to the organisational needs of public health, the connection of these with the Sustainable Development Goals, coordinating a state strategy that integrates different health sectors and actors (social services, education, transport, third sector...) in a generous and cooperative network, and developing an innovative, benchmark and prioritised public health communication strategy, among other functions.  

The nature of Spain's political-administrative organisation requires the agency to be a networked centre, made up of a central coordinating node, regional nodes and thematic nodes

Given the internationalisation of health, it will be essential for the PHEA to collaborate closely with supra-state bodies (European Union, WHO, etc.). Similarly, the nature of Spain's political-administrative organisation requires the agency to be a networked centre, made up of a central coordinating node, regional nodes (public health centres or bodies of the regional and local administrations) and thematic nodes (excellent scientific bodies, universities, technical centres, etc.). The agency should work in close collaboration with the Autonomous Regions to respond to their different public health needs. All of the agency's functions should also be carried out in collaboration and direct communication with the Autonomous Regions.

There are some international and national benchmarks that can serve as inspiration for the new agency. One example is the New York City Department of Health, currently one of the largest public health agencies in the world, which attracts and recruits different professionals, epidemiologists and other researchers. Another good example is provided by the Barcelona Public Health Agency, which has been performing all public health functions in the city for almost two decades.

What should be the role of the State Public Health Agency?

The future agency should perform at least the following functions:

i) Population health surveillance from a comprehensive model based on the social determinants of health (work, housing, etc.).

ii) Information management for preparedness and response to health emergencies such as the current pandemic, but also others arising, for example, from the ecological crisis.

iii) Coordination with European and international bodies, such as the World Health Organisation or the European Centre for Disease Control.

v) Assessment of the impact on health and equity of different legislative projects (anti-smoking law, housing law, etc.) and other public policy measures.

vi) Development of a health strategy in all policies, taking into account the social determinants of health and promoting the One Health approach, which brings together efforts to achieve optimal health for people, animals and the environment, all in line with the Sustainable Development Goals.

vii) Development of a communication and response strategy in response to demands or information needs in administrations and society.

viii) Support in the development of basic legislation, and development and transposition of EU legislation.

ix) Guidance of research and training priorities in public health.

x) Support and advice to all administrations for decision-making affecting public health.

The development of the functions of the EPSHA will require the recruitment and retention of a highly qualified and interdisciplinary workforce. EPHA will also need mechanisms to avoid capture of its work by the powers that be. The credibility, legitimacy, leadership and prestige of the institution will depend on these mechanisms and its ability to be consistent with its scientific and ethical values.

We believe that the creation and development of this agency is decisive for the necessary updating of Spanish public health, in accordance with the highest scientific and administrative standards required in the 21st century to protect the health of our population.

The Spanish Society of Public Health and Health Administration (SESPAS) created a large working group of 28 experts, who collaborated in different phases until the final SESPAS Report and the article in Gaceta Sanitaria were published.

This article was originally published in the SINC agency.

Manuel Franco is an epidemiologist, professor and researcher at the Universities of Alcalá and Johns Hopkins. Spokesperson for the Spanish Society of Public Health and Health Administration SESPAS.

Daniel G. Abiétar is a resident doctor in Preventive Medicine and Public Health, Hospital del Mar, Barcelona.

Rosa Urbanos is an economist at the Complutense University of Madrid, President of SESPAS.