Jesús Aguirre, Minister of Health of Andalusia – Spain’s most populous region – explains in detail the COVID-19 protocols executed by his ministry and how they managed to keep ICU saturation levels low. In addition, Aguirre comments on the end of the region’s auction model in the procurement of medicines, a partnership with Fujitsu that resulted in local production of ventilators, and the fact that Andalusia has been trying to unify both private and public healthcare systems, arguing that “there should only be one healthcare, belonging to everyone and for everyone.”

You were appointed Andalusia’s Minister of Health at the start of 2019, which gave you about a year to prepare the region for the pandemic that was about to hit. Can you walk us through your experience as the leading health official of Spain’s most populated region?

First, thank you for the opportunity to speak to your audience. When the coronavirus first came to Andalusia, we were not caught entirely unprepared because of our previous experience with a Listeria outbreak a few months earlier, in August of 2019 – Andalusia had the second worst outbreak in the world that year. Listeria is a serious infection usually caused by eating food contaminated with the bacterium Listeria monocytogenes. That outbreak forced us to completely change the public health team, strengthening Andalusia’s epidemiological surveillance system at a time when insufficient importance was given to viruses and bacteria.

On January 27 of 2020, a little less than a month before the WHO officially declared COVID-19 a global pandemic and the first case was confirmed in Spain, Andalusia put in place a coronavirus advisory team made up by the scientific community. The national Ministry of Health had indicated that we should expect just a handful of cases, but we felt the need to get ahead of the situation; that same advisory team – which includes the society of biology, epidemiology, public health, preventive medicine – continues to work with us. The first challenge was transforming Andalusia’s public health approach and we accomplished our goal before COVID-19 arrived to our community.


In which ways did you and the MoH transform Andalusia’s approach to public health?

The changes where on both content and form. First, we moved many of the system’s daily operations online, especially the epidemiological surveillance system, unifying incoming information from the public and private systems under the region’s Ministry of Health. As Minister, I assumed control over both systems and put in place highly qualified experts on preventive medicine and public health. Their expertise has allowed us to manage the six outbreaks more efficiently than most Spanish regions; Andalusia’s hospitals have never been fully saturated throughout the entire pandemic, which has allowed us to be supportive of other regions, sending ventilators and receiving external ICU patients. We were able to insulate nursing homes right from the start, taking note from what was happening in the north of Italy; my team sent a clear warning of an upcoming “explosion.”

Another important challenge was the scarcity of supply of personal protective equipment and medicines. To overcome it, we stimulated our industrial base to produce masks for our region and the rest of the country. However, the national government took control of Andalusia’s plant a couple of months afterwards in order to distribute them across the country.


Can you elaborate on the manufacturing capacity that Andalusia had at its disposal, how it was utilized, and the involvement of the national government?

The plant located in our region was relatively small but increased its capacity quite rapidly. The state of emergency in Spain was declared on March 14, 2020. Two days before, the country’s Minister of Health called me and said that they were confiscating the plant, which was producing around one million masks per week. We accepted the decision and they started distributing them for communities with larger outbreaks.

But Andalusia’s efforts did not stop there. We secured an agreement with Fujitsu and the University of Malaga to produce automatic ventilators, named “Andalucía Respira” (Andalusia Breathes), which were sent to Latin America. The Andalusia-made ventilators are small and portable making them useful for developing and newly developed countries. The price we established for the first 600 ventilators for those countries was €1 at a moment when the market price is around €700. Of course, they are not the most sophisticated machines in the market but get the job done and were approved by the competent authorities.


What other practical lessons did the Ministry learn during the pandemic?

The pandemic represents a development opportunity, and our team has learned a lot, especially since each wave and variant have posed different obstacles. After giving over 18 million vaccines in a short period of time, our system has learned a lot about inoculation, resulting in a record number of seasonal flu vaccines last year and the inclusion of the 13-valent pneumococcal conjugate vaccine for people over 60 years of age – making Andalusia the first region in the world to do so – because we realised that it could prevent severe pneumonia cases.


Do you have preliminary results on the effects of your pneumococcal vaccine strategy compared to other regions that have not done this?

No, the scientific evidence studies are ongoing, and results have not been made available yet. What we have are mortality rates per 100,000 people and Andalusia is way below the national average, the same has happened with ICU occupancy rates.


Reflecting on these two years, which decision do you regret the most?

Our grand mistake was banalizing the pandemic, we were proactive but not proactive enough. I ask myself what could have happened if we had reacted one week earlier. We knew that on 28 of February 2020 there was a worrisome number of cases in Madrid and failed to stop our people from travelling there during a long holiday weekend, resulting in a surge of cases during the first weeks of March. On this point, I should point out that Andalusia was opposed to allowing large gatherings for that year’s Women’s Day.

On the positive side, our team has taken successful measures during the latest waves, avoiding the introduction of new restriction measures. The pandemic has left many lessons learned but also doubts about the future.


You have mentioned some discrepancies with the national government related to pandemic response. What can you tell us about the dynamics of the relationship between the regional and national governments?

Our relationship with the central government is defined by them as “co governance” but it has lacked discipline. From the start, we asked for a unified pandemic law that could set a standard for everyone because the virus does not care about territorial political borders. Andalusia advocated for an equal and cohesive inter-territorial response.

Once the state of emergency decree was announced, each autonomous community interpreted its responsibilities in a different way; that is my biggest complaint against the central government. Co-governance did not exist because the country failed to establish a law that applied to everyone.


Can you point to specific changes that must happen in Andalusia’s healthcare system?

First, we must continue to modify public health protocols. Second, we have detected a deficit in infrastructure and invested more than one billion euros in hospital and primary care infrastructure, adding 1,600 hospital beds and 450 ICU spaces. We have also increased our hiring rate by 20 percent; the regional healthcare system employs approximately 130,000 people, many of them new. Andalusia has added 3 billion euros to healthcare budget in three years, totaling 12 billion per year.


What about the role of the private sector in helping transform the region’s healthcare system?

Spain’s national healthcare system is characterised by universal access, quality and gratuity. It is a successful system that compares favourably against any other in the world, it is similar to the British model. Being decentralised, you can find different models depending on each region; there are some focused on the private sector such as Catalonia’s.

In our case, Andalusia has been trying to unify both private and public because there should only be one healthcare, belonging to everyone and for everyone. The good-bad dichotomy of public vs private that reigned here for 36 years is over. I am the minister of health, not only of “public health.” My goal is to gather resources in the benefit of patients regardless of their precedence. Breaking old schemes has been a long struggle; we have been in charge for three years after 36 of socialist rule.

I personally sit down with leaders from the private sector and ask them pointblank how they can bring research to Andalusia since we have great infrastructure, top class researchers and research institutions. We brought an expert from MIT that sorted the more than nine million anonymised health records so that we can make use of them. What I ask of multinational research companies is to bring phase I, II and III clinical studies to the region.

When the time comes to have a conversation with a company that, to put an example, receives 100 million euros from our administration, I ask them how that investment will benefit Andalusia beyond the products offered. Why should all their R&D investment go to Barcelona or Madrid? We have the largest healthcare system in the country.


What has been the response from those companies?

The response is usually positive. We have signed agreements customised to the expertise and interest of each company, we know the therapeutic areas they want to develop, so the goal is to match their interest with Andalusia’s.

The agreements include detailed figures of the budget needed, the nature of the research, protocols, specific hospitals, and so on. The way we work is putting all the cards on the table to find common ground.


One of the most contentious elements of Andalusia’s healthcare market in recent years was the auction model in the procurement of medicines, something that your government promised to end. What can you share about that experience?

As a medical doctor that has spent many years in politics, I never promise anything that I cannot deliver. I told the electorate that the system of auctions for medicines resulted in access inequality for patients, shortages and a non-competitive market. The auction system proved to be a failure, and if not, why didn’t the PSOE (Spanish Socialist Workers’ Party) implement them in other regions it controlled?

We promised that the auctions would end, and Andalusia would follow the national law. The president of Andalusia, Juan Manuel Moreno, gathered all stakeholders and put an end to them in December of 2020. Our priority today is to join forces with everyone, including on research and biosimilars. We are very interested in biosimilars because they are the alternative for the products that have the largest impact on our budget. Today, the cost of medicines is at a very high level and growing by double digits inside hospital pharmacies; on the other hand, prices in community pharmacies are under control. Let’s not forget that Andalusia is similar in size to Portugal.


The big questions for many on the outside remains the secret behind Spain having one of the world’s largest life expectancy rates?

I am a medical doctor that happens to serve as minister of health, but a doctor first. My intention is to apply everything I learned as a small-town doctor, coming from what I call the university of worn shoes, to improve the health of Andalusia.

Spain’s high life expectancy can be traced to many things, we can speak about our diet, weather, and genetics. But we cannot take it for granted after what has transpired in the last two years, the expectancy rate has decreased due to the pandemic. If we are to improve the figure again, we must help people be independent so that the extra years are well lived.