Health Policy Monitor
Skip Navigation

New flu H1N1, ongoing strategies in Catalonia

Partner Institute: 
University of Barcelona
Survey no: 
(14) 2009
Anna Llupi and Josep Jimnez
Health Policy Issues: 
Public Health, Prevention, System Organisation/ Integration, Responsiveness, HR Training/Capacities
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no yes


The implementation of preparedness plans for the new strain of influenza have made it necessary to adapt surveillance systems, to coordinate and prepare all levels of health care services and to update training programs. Previous preparation and existing coordination structures have helped to archieve a rapid response to the new situation. Virtually all the decisions taken have been scrutinized by media and technical debates have reached the population on several occasions.

Purpose of health policy or idea

Preparedness and resource allocation for Catalan Health Services under the new H1N1 Flu strain.

Main points

Main objectives

In this report we want to address the response of Catalonia to the WHO alert concerning H1N1 Flu and to review the measures being taken as well as the related public debate.

Type of incentives

Financial and non-financial.

Groups affected

Health services planners, health professionals, other sectors: schools, companies and media

 Search help

Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low very high very high
Transferability strongly system-dependent system-dependent system-neutral

Some innovations have been included in the surveillance and response system. Some of them were planned in advance, some others have been suggested by the WHO and the Spanish Ministry of Health.

Any effort in coordination will have a positive impact on the structure of the health system. However, some long term public health topics are being delayed because of the new flu.

Adopted measures  may be similar everywhere else, but the characteristics of the Catalan Health System, where the Health Department of the Catalan Government is responsible for planning, evaluating and funding, whereas providers are hired separately, makes the coordination very system-dependent. 

Political and economic background

When the WHO launched its response system to the emergence of a new flu strain, Spain began to adapt its pandemic preparedness plan for the new challenge. The Spanish plan for pandemic preparedness and response was developed during 2005 and instructed the various autonomous communities to develop their own plans. Catalonia presented its plan in 2006 and it has been updated on several occasions. Among other things, during the preparation period Spain updated its legal framework in order to adapt it to the international health regulations.     

Complies with

Need to adjust to WHO guidelines concerning H1N1 pandemic.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no yes

Origins of health policy idea

Pandemic Flu preparedness plans had already been devised in Catalonia since the first appearance of WHO recommendations; the first plans date from 2006. Several hospitals presented their own plans to the whole network in 2007 as an example for all the other health centers. After the H1N1 alert, these plans have been updated. There has been an special effort to coordinate all levels of health care.

Initiators of idea/main actors

  • Government: In Spain, health competencies are decentralized. The Spanish Ministry of Health has created the Inter-Territorial Council which decides the vaccination and treatment criteria, purchases vaccines and antivirals, and defines the main guidelines.
  • Providers
  • Payers
  • Media

Approach of idea

The approach of the idea is described as:
renewed: Most of the policy consists of an adaption of previous preparation plans to the new situation. There has been, though, a substantial adaption to the new circumstances and epidemiological evidence.

Stakeholder positions

Most of the adopted policies have been rather  technical and found no substantial opposition.

Actors and positions

Description of actors and their positions
Central Spanish Governmentvery supportivevery supportive strongly opposed
Catalan Governmentvery supportivevery supportive strongly opposed
Health Care Personnelvery supportivesupportive strongly opposed
Health Services Providersvery supportivevery supportive strongly opposed
Catalan Health Servicevery supportivevery supportive strongly opposed
Mediavery supportiveneutral strongly opposed

Actors and influence

Description of actors and their influence

Central Spanish Governmentvery strongstrong none
Catalan Governmentvery strongstrong none
Health Care Personnelvery strongstrong none
Health Services Providersvery strongvery strong none
Catalan Health Servicevery strongvery strong none
Mediavery strongvery strong none
Central Spanish Government, Catalan GovernmentHealth Services Providers, Catalan Health ServiceHealth Care PersonnelMedia

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Thanks to the previous plans for alert preparedness and response to emergencies , the health personnel responsible for the emergencies were alerted only a few hours after the first WHO warning. Within 48 hours a small set of guidelines for healthcare professionals was released, containing useful information about the new virus.

Flu surveillance is usually based on detection and control of clusters of cases and a network of sentinel doctors who report  morbidity/mortality related to influenza activity, and send samples to reference laboratories. In May,  a record of severe cases related to the new strain was established, which has been in operation since then.

Regarding the activity and resource availability, the Catalan Health Service has a comprehensive emergency  policy which coordinates all the actions from different levels of care services (PIUC). This plan is operative each season in December-March and summer. It  includes data of hospital usage and the network of primary care  in order to hire more services if necessary and to efficiently  distribute the workload across the network. This implies monitoring bed occupation together with scaling and improving resources. This plan generates a weekly newsletter to inform professionals and the general public. This platform is also  responsible for informing the structures of accountability in the administration, hospitals, primary care and emergency services, who are updated via SMS on their  cell phones. The system is running this year from September the 1st and has incorporated some changes in order to respond more effectively to the present situation. Some variables related to the flu are collected and the daily time of declaration has been advanced, in order to have more time to take organizational decisions. This year, the activity of primary care and referrals from these centers are collected more comprehensively.

During the PIUC season centers must submit their protocols to respond to the ongoing demand, either through the optimization of existing services or partnerships with other services. This requires a protocol for coordination and identification of available resources and analysis of resource requirements. This year, plans have incorporated estimates of demand generated by the new influenza strain. The emergency plans developed by the hospitals and the other health centers are the organized response of each center to an extraordinary demand caused by the new influenza A. These plans should meet the guidelines of the Inter-Territorial Council and include staff training and relocation of health care workers in case they have basal risks. The emergency plan should be activated whenever there is a generally well quantified disproportion between the demand for health care and the resources commonly available. The activation of the plan should always be accompanied by the agreed definition of severity. The level of intensity always depends on the ability of the care center at a given time. The activation of the Plan should be the more cost efficient option in relation to the human resources and healthcare spaces.

The Catalan Health Service has a telephonic service that is designed to facilitate access to health services, which works in coordination with transport services and emergency care. At the same time, it provides health services such as a telephonic advice and support for people requiring it. The Health Information Phone Line has developed an algorithm for phone calls and has trained its staff to provide a level attention to the mild flu symptoms.

A total of 16,000 companies and businesses have been asked to adapt their needs to a possible lack of resources and to protect the health of their workers. Schools have also received instructions concerning hygiene habits. The school year was not delayed because it was considered that the virus was already circulating in the population.     

Monitoring and evaluation

After seeing the behavior of the new strain in the southern hemisphere, there is an intensive debate in the scientfic and professional community. Some think that measures are exceeding needs and others that we are already late to meet demand. The administration is preparing the system for the worst reasonable case trying not to generate alarm among the population, which could increase the demand of healthcare services unnecessarily.

A wide debate about who is supposed to prescribe and which is the best way to distribute and deliver vaccine and treatment has led to a revision of distribution and storage channels. Any alert generated by an uncertainty that implies changes in public health policies can be easily interpreted by the media, and therefore by the population, as an alarm. Given the strong impact that media  had after the apparition of this new flu strain, the various political and technical decisions were subject to a tight monitoring by the media. Several technical discussions have reached the population (changes in the indications of the vaccine and the availability) and some political parties used as a weapon of political confrontation, sometimes without enough technical information.

These misunderstandings have motivated the proliferation of e-mails and other media ranging from criticism to the interests generated by the industry to the exposition of conspiracy theories about the origin of the virus or its alleged nonexistence. These messages show  the most extreme alarm or the absolute unconcern, conveying messages that discredit the measures taken by the administration and, for instance, promote non-vaccination.  

Given this, the health department has created several educational materials and has decided to issue a weekly statement that reports the rate of infection and the number of severe cases. All the communication departments of  health centers are now coordinated in order to broadcast messages which are understandable and transparent. Key informants have been selected in each health center in order to deal with media.

Expected outcome

The risks of an unknown new strain has accelerated the development of systems of preparedness and emergency response, useful in other situations. 

This situation has forced to improve the training of health professionals on patient safety and habits of the healthcare worker  and the general population with regard to biological hazards.

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable system more equitable system more equitable
Cost Efficiency very low neutral very high

This policy strengthens coordination and therefore may have a positive impact on quality.

The Catalan Health Service has made an effort to provide the same health care everywhere . Whenever the system is unable to respond, other providers are asked to provide services, trying to make the system more equitable.

There was a good level of coordination of all levels of assistance of the healthcare system and healthcare workers have been very professional and supportive. On the other hand, at the same time that more data about the behaviour of the new strain is available, several measures may seem unnecessary.


Sources of Information

Author/s and/or contributors to this survey

Anna Llupi and Josep Jimnez

 Anna Llupià works at the Preventive Medicine and Epidemiology Department of Hospital Clínic of Barcelona and Josep Jiménez is the Head of the Health Services Evaluation Division at the Catalan Health Service.

Suggested citation for this online article

LLupià, Anna, and Josep Jiménez. "New flu H1N1, ongoing strategies in Catalonia". Health Policy Monitor, October 2009. Available at