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The caterpillar and the butterfly: public health in Spain
  1. A Segura
  1. Public Health Department, University of Barcelona, Spain; andreus{at}

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    In Spain, like in other countries, public health services are a small part of the health system. They are under the mandate of either local or regional health authorities and they are responsible for health protection and promotion activities, which include the surveillance and control of communicable diseases as well as community outbreaks and, also, the interventions to prevent and respond to health hazards or dangers.

    The importance of public health in the health system is marginal. It amounts to only 1% of the total health budget, and it is not clear that these resources are used effectively. Many health information campaigns look more like propaganda from the health administrations themselves than proper health interventions.

    Most public health professionals are civil servants. The population identifies them as the administration’s agents and, in some cases, as servants of health politicians. Thus, public health professionals are sharing with politicians a shortage of confidence by the public.1 Of course, this situation throws a negative impact over public health functions and interventions, particularly in the fields of risk assessment and communication.

    Despite these limitations, public health offers the only perspective available to assess the health problems and their determinants at the population level. On the other hand, the contributions to health protection and promotion from other social and public sectors like environment, agriculture or education could be improved with the knowledge and skills of the public health professionals. Unfortunately, public health rarely assumes the societal leadership to deal with the community health concerns and expectations. Nevertheless, a public health approach is also necessary to evaluate the effectiveness, safety, efficiency, and relevance of healthcare services.

    Therefore, it seems necessary to regain public confidence by changing the current public image and recovering professional autonomy; to increase its technical competence and service commitment, and to acquire specific weight in front of decision makers. It will be pointless to request more resources for public health in the absence of an alliance with other healthcare stakeholders with relevant community functions. The existence of community based primary healthcare teams in our health system provides an opportunity for public health services to get closer to the needs and expectations of the population, as proposed by the WHO initiative “Towards unity for health”.

    Public health practice in Spain needs a radical change, like a metamorphose, to transform the ugly caterpillar into a pretty butterfly.


    I am indebted to Itziar Larizgoitia and Albert Oriol Bosch for their comments.


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