One week after a major protest in support of universal and public health care took place in Madrid, family physicians and pediatricians working in the region’s primary health care services launched an open-ended strike. They have now entered the third week of the industrial action, as negotiations with the regional government continue. The health workers are fighting for more investment in primary health care and more humane working conditions for all employees in the system.
People’s Health Dispatch met with Alberto Cotillas from the Madrid Society of Family and Community Medicine (Sociedad Madrileña de Medicina Familiar y Comunitaria, SoMaMFyC) to learn more about the action and what lies ahead.
People’s Health Dispatch (PHD): A couple of weeks ago, health workers in the Madrid area joined thousands of people in a protest for public health care. A few days later, doctors working in primary health care services went on strike. How are these two events connected? Do the strikers share grievances with the patients and other people who protested on November 15?
Alberto Cotillas (AC): Primary health care in Spain in general, but mainly in Madrid, has been decaying over the last few decades mainly because of the lack of funding. This has led us to be totally overwhelmed by the number of patients coming to see us, with less and less doctors employed in the system every day. Today, thousands of patients in Madrid don’t even have a primary doctor of reference. And those of us who remain in the system meet with 50-70 patients per day.
You can’t provide good quality care to that number of people in a seven hour shift. Because of that, we have to take more time from what is supposed to be our free time. That doesn’t only limit time for rest or leisure, it also means we have to abandon activities such as community engagement or action, or research, or tutoring medical students. All in all, it means we’re up to our head in visits, but we don’t actually have enough time per patient to ensure the best care quality, or to do anything else that’s related to health and the health system.
PHD: And how has the strike been progressing until now? What are the main requests that you have raised with the government?
AC: Some of the main goals of the strike are to have better funding for primary healthcare, because, at the moment, Madrid allocates only 10.7% of its whole health budget to this level of care. Primary health care in Madrid is actually underfunded even in comparison to other regions of Spain, where the mean is around 14%.
Another point is the number of daily visits. Now, the government is saying they would guarantee a cap on daily visits. It would be 34 patients per day for family doctors and 24 patients per day for pediatricians. At the moment, this doesn’t sound completely convincing. The government might be offering this kind of cap, but more people will still be coming in for medical assessments. It’s not clear what’s going to happen to them in case this cap is implemented. Ideally, there should be more recruitment in primary care to accommodate these needs, but the government is not saying anything about that. Because of that, we don’t really think this offer of theirs is going to be feasible.
But, coming back to the overall situation with the progress of the strike, the main point is that the negotiations are a bit stuck right now, primarily when it comes to the budgetary requests.
PHD: You mentioned that Madrid invests less in primary care compared to other regions. At the same time, it’s one of the richest regions in the country. Is there a reason behind this low prioritization of primary care or is it just coincidence?
AC: I guess that comes down to how the regional government decides to allocate the money inside the health care system, and that’s a political decision. This region has been governed by the same party for decades, and I guess that the current status results from a political decision to underfund the public health system in general and the primary health care system in particular.
Someone could make the point that because bigger hospitals are centralized in Madrid, they require more funding than elsewhere. Madrid has lots of big hospitals that are a reference point for all of Spain because they have special techniques and more advanced technologies, and that requires money. But still, if you compare the situation here with other richer regions, like Catalonia or the Basque country, they still get a bigger percentage of the health budget to go towards primary health care.
I would say it’s mainly a political decision. In medical circles, we are prone to believe that many of the people from regional political parties – not only the one in power now, but generally – don’t really use the public health system or primary care services. They can go to the private sector and get their health issues sorted out there. They probably think about the public system in a different way than we do, because, if you’re not using it, if you’re not part of it, it might be difficult to imagine what needs to be changed and what’s the best way to do that.
The private sector in general has grown stronger. Now even if you’re a worker in the public sector, you’re offered the choice between accessing care in public or private health institutions. But, if you’re a public worker, wouldn’t it make more sense for you to use the public sector, which has been built for the benefit of all? And, if you choose to go to the private sector, with time it might become less clear for you why we have a public health care system, which complicates things further.
PHD: Since we’ve already mentioned the regional government in Madrid, I believe regional president Isabel Diaz Ayuso was called out multiple times for her stances on health, including during the COVID-19 response. In the context of this problematic approach to health care they’ve adopted, what was their reaction to the strike?
AC: I think the most significant thing they did was not to talk about it. I mean, the president didn’t really talk about it much. They made some general remarks about how negotiations were ongoing and so on, but the truth is that they are not acknowledging that the problems that we have pointed out exist. They’re saying, “yeah, we’re doing all these things to improve the salaries of health workers,” and so on.
It is true that they have been designing some kind of improvement in our salary, but we’re not striking for that. We are not striking over our income, we’re striking because we want to work in a better system that lets us care for our patients in a proper way, dedicating to each patient the necessary amount of time.
Because it’s really sad when you have a patient with you, you’re already running 30 minutes behind on your timetable, and the waiting room is full of other patients. And then the patient who is with you breaks down for some reason, they need more time or they start crying or something like that, and you’re wondering, “how am I supposed to provide this person with proper care? How do I let them take the time they obviously need, and do the same with the people who are waiting outside?”
That’s what we are striking for. We want to work in a way that is better for both our patients and for us. And that’s also what the government is not acknowledging, and instead they’re focusing on other things. For example, recently there was a leak of some audio messages from some of the strikers. It wasn’t anything bad, just people talking about what could and should be done. But the ruling party spun this in a way to say that the strike was organized for political reasons, to harm them ahead of the elections that are coming up in May next year.
Essentially, they are ignoring what we are saying and going along a path that is easier for them: painting this as a political attack, rather than tackling the problems that we have warned them about.
PHD: Are there any other requests put forward by the strike, in addition to better funding for primary care and strengthening the health system overall?
AC: Well, I guess that from outside it can look a little bit narrow, like we’re focusing on the funding and the time available for consultations. But what we are fighting for is actually the spirit of primary health care. We want to make primary care good not only for us, but for our patients, for our fellow workers like nurses and administrative staff.
We all deserve to have a better system, and, in order to have a better system, we need to make room for more funding and more time to spend with patients. That’s what this action is about: we are here to work in our health system, for our fellow citizens.
That, I feel, is quite right about this strike. It’s not a salary problem, it’s not a monetary issue in an individual sense. It’s about the collective spirit of primary health care overall.
PHD: That’s something that we’ve heard from many strikes that have been going on during the COVID-19 pandemic – that workers’ aren’t going on strike because of their salaries alone, but because they want better and stronger public health systems. More often than not, this argument is ignored by governments, but is it taken seriously by the users? Are patients supporting your strike?
AC: Mainly, yes. The media polls show that patients support the action. Of course, we maintain minimum services to make sure that anyone in need of immediate care can receive it. When we talk to those people, when they’re leaving the consultation room, the impression we get from them is mostly, “okay, I hope your protests go well, and I’m with you in some way!”
There have also been demonstrations in support of our requests in different parts of Madrid, organized by neighborhood and community groups. I think that’s also the thing about the health system in Spain – most of the population feels that it’s one of the main strengths of our social system. We all feel that we should fight for it. So, to come back to your question, yes, I think that most of the time the population stands with the workers when there’s a demonstration like this.
Of course there are some people who are angry. I understand that, because they waited for a long time for an appointment and now they won’t be able to do this or that consultation. But I do hope that with time we’ll all understand that it’s something that we are doing to build a health system which is better for all of us.
PHD: What about support inside the health sector? Who are the organizations coordinating and supporting the strike?
AC: In the first place there are the organizations active in the field of primary health care, along with the trade unions. So, for example, the Association of Physicians and Higher Graduates of Madrid (AMYTS) is one of the organizations that launched the strike action. Then there are unions like the Assembly of Health Workers (MATS), and actually most of the other unions in health care.
In addition to that, there are also the professional associations, like the Madrid Society of Family and Community Medicine, which is a member of the national association. I think even the medical council, which is one of the key associations in this field, because they grant us our professional licenses, has expressed their support. And then there are the organizations from other professions, mainly nurses’ associations, who are all supporting the strike.
In all honesty, I think that’s because it would be really difficult to go against what we are fighting for. I mean, you might have your problems about how it’s organized, but it would be difficult to dismiss the point of the strike because everyone who works in the primary health care system experiences the problems I have described.
PHD: And what are your impressions based on how the strike has been going on for now? What do you see lying ahead?
AC: I see us all fighting together for our health system in general, and in the nearer future in particular for primary health care. I know that our companions in hospitals support our actions, too. And I think that this strike has shown people that we can actually hope and fight for better things. People inside and outside of the health sector were already tired of how the system looked before the strike; they were overwhelmed by the amount of work and the inaccessibility of quality care – and they didn’t feel like there was space to fight for a better system. But, I think this strike has shown us that we actually can do it. So we’ll try fighting a little bit more.
People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch. For more articles and to subscribe to People’s Health Dispatch, click here.
