title: [Implementing strategies to improve the institutional governance of the Spanish National Health System].
abstract: The 2008 economic crisis made the issue of good governance more present and visible, but the debate risks stalling in an academic and political discourse that barely exceeds the declarative. We acknowledge the existence of noteworthy documents from scientific medical societies and some institutional proposals that point towards promising changes. Viewing good governance as accountability, participation, transparency, intelligence and integrity, our objective is to identify the determinants of inaction and remove the barriers that prevent the adoption of rational and widely agreed-upon proposals. This led us: 1) to allocate the proposals to their appropriate governance level (macro, meso, micro and system environment) so as to more directly engage the agents of change; and 2) to highlight some decision nodes that can act as levers to catalyse selective transformations and to initiate the change processes. Taking into account the diversity of actors and scenarios, a top-down rational, integrated and reformist strategy for the whole Spanish National Health System does not seem likely or viable. Therefore, the purpose of this paper is to promote changes, setting a targeted and reasoned agenda to visualise key issues and to enable multilevel and multidimensional thinking and advocacy of health-sector and society stakeholders.
authors.affiliation: Departamento de Planificación y Economía de la Salud, Escuela Nacional de Sanidad, Instituto de Salud Carlos III, Madrid, España. Electronic address: jrepullo@isciii.es.
authors.forename: José Ramón
authors.initials: JR
authors.lastname: Repullo
authors.affiliation: Departamento de Salud Internacional, Escuela Nacional de Sanidad, Instituto de Salud Carlos III, Madrid, España.
authors.forename: José Manuel
authors.initials: JM
authors.lastname: Freire
mesh_terms: D009313:National Health Programs / Q000458:organization & administration*; D013030:Spain
keywords: Buen gobierno; España; Good governance; Health policies; Health systems; Organisations; Organizaciones; Políticas sanitarias; Responsabilidad social; Sistemas sanitarios; Social responsibility; Spain