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[ES] La gestión es un término amplio y polisémico; la historia del pensamiento empresarial va definiendo en una serie de funciones (planificar, organizar, incorporar personas, dirigir y evaluar), que pueden sintetizarse en coordinar la producción y motivar a los que participan en ella. La gestión tiene un núcleo común, pero depende mucho del contexto en el que se aplica: las empresas industriales que fabrican bienes, las que prestan servicios, o las que dichos servicios son profesionales; la sanidad es un caso particularmente especial y complejo de estas últimas. En la sanidad, y especialmente en entornos públicos, se produce una gran asimetría de información entre proveedores y usuarios; de ahí que el término “demanda” precise complementarse con la “necesidad”; y también que los resultados de valor haya que medirlos en términos de efectividad, seguridad, calidad, impacto (individual y poblacional) y eficiencia. Los sistemas sanitarios modernos se estructuran en grandes redes, a partir de sistemas de aseguramiento colectivo de riesgos de salud; esto diferencia la macro-gestión (financiación-aseguramiento), la meso-gestión (gerencia de centros y servicios), la micro-gestión (áreas y unidades clínicas), e incluso una nano-gestión (las interacciones y decisiones clínicas individuales). Cada uno de estos niveles obliga a activar diferentes instrumentos y estilos de gestión. La gestión es una actividad sintética integradora y adaptativa; para ello debe tener un gran arsenal de marcos conceptuales y de herramientas de actuación, que se activarían en función de los problemas y desafíos de las organizaciones. [EN] Management is a broad and polysemic term; the history of management thought is defined in a series of functions (planning, organizing, staffing, leading and controlling), which can be synthesized in coordinating the production and motivating those who participate in it. Management has a common core, but it depends a lot on the context in which it applies: industrial companies that manufacture goods, those that provide services, or those that perform professional services; Health is a particularly special and complex case of the latter. In health, and especially in public environments, there is a great asymmetry of information between providers and users; hence the term “demand” ought to be complemented with the “need”; and also that the results of value have to be measured in terms of effectiveness, safety, quality, impact (individual and population) and efficiency. Modern health systems are structured in large networks, based on collective health risk assurance systems; this differentiates macro-management (financing-assurance), meso-management (management of centers and services), micro-management (areas and clinical units), and even nano-management (individual clinical interactions and decisions). Each of these levels requires the activation of different instruments and management styles. Management is a synthetic integrative and adaptive activity; for performing this role, it must have a large arsenal of conceptual frameworks and action tools, which would be activated according to the problems and challenges of the organizations. Sí

[EN] The article described the historical context of health management training in Brazil and aimed at identifying similarities and differences between this training in Brazil and Spain, using qualitative approach and comparative method. Data sources included the scientific literature, official documents orienting interventions in health management training, and semi-structured interviews. Interviews were conducted with managers selected on the basis of currently occupying or having occupied management positions, besides experience and participation in shaping policies in health, totaling four managers in Brazil and six in Spain. Based on thematic content analysis, the results were related to the category of “institutionality” according to the following themes: health and education policy, management training policy, and professionalization. A common element was that Brazil and Spain both adopt health protection as a civic right through universal public health systems. The most significant difference relates to population coverage, nearly complete in Spain in the late 1990s. The study showed the lack of a national training policy for managers in both countries and that such a policy is essential for professionalization in health management. Although the theme of professionalization exists in Brazil, in Spain it has distinct institutional characteristics, having achieved important recent progress. [PT] Este artigo descreveu o contexto histórico da formação em gestão em saúde oferecida no Brasil e buscou identificar suas semelhanças e diferenças com aquela oferecida na Espanha. Adotou-se uma abordagem qualitativa da realidade e o método comparado foi empregado. Como fonte de dados, utilizaram-se a bibliografia científica, os documentos oficiais, que orientam as intervenções no campo da formação em gestão em saúde nos dois países, e a entrevista semiestruturada. As entrevistas foram realizadas com gestores selecionados pelo fato de estarem ocupando ou de terem ocupado cargos de gestão e que tenham participado da conformação da política de saúde, totalizando quatro gestores brasileiros e seis espanhóis. Apoiados na análise de conteúdo temática, os resultados se relacionaram com a categoria “institucionalidade” a partir dos seguintes temas: política de saúde e educação; política de formação de gestores; e profissionalização. Identificou-se como elemento comum o fato de tanto o Brasil quanto a Espanha adotarem a proteção à saúde como direito de cidadania por meio de sistemas públicos e universais de saúde. A diferença mais significativa diz respeito à cobertura populacional, alcançada na quase totalidade na Espanha no final dos anos 1990. Evidenciou-se a inexistência de uma política nacional de formação de gestores nos dois países, considerada central para a profissionalização da gestão em saúde. Ainda que o tema da profissionalização esteja presente no Brasil, na Espanha assumiu contornos institucionais distintos com avanços significativos em período recente. Sí

The economic crisis (2009-2014) and the austerity policies (2010-...) have notably affected Spanish society, its public services and the public health system. Unemployment and labor regulation has deteriorated the labor market, creating poverty and inequality, and consolidating low salaries, part-time work and contractual precariousness. No short-term impact on health (morbi-mortality and perceived health) was observed (except perhaps in mental health), but problems are expected in the medium-long term. The austerity has significantly affected the National Health System (NHS), imposing budget cuts close to 10%, through linear reductions in salaries, hiring and spending; but the NHS has been resilient, although it has accumulated structural tensions, has exhausted its reserves, and has accumulated waiting lists and criticism from patients. The need for reforms is clear, but distrust among all agents prevails. The political change of 2015 (end of bipartisanship), the Catalan conflict since 2017, the change of government in 2018 (PSOE), and the elections of 2019, will influence the next future agenda, oscillating between a liberal-conservative model (public health stagnant with increasing flight from the middle classes to private health care), and a social reformist one (reinvestment in health care, although with controversies in management models). Sí

[ES] La crisis económica y fiscal del año 2008 ha irrumpido en el debate de la sostenibilidad sanitaria; en algunos países, como España, se han impuesto duras políticas de consolidación fiscal y austeridad en los servicios públicos. El marco institucional y de gobierno del Sistema Nacional de Salud (SNS) tras las transferencias de 2002 tenía importantes debilidades, no evidentes en la etapa de crecimiento rápido, pero que eclosionan a partir de 2010. En este trabajo se exponen los cambios en regulación y gobierno desde la perspectiva estatal y del SNS, tanto los de carácter general (con clara iniciativa de las autoridades económicas) como los más específicos de la sanidad. El Real Decreto Ley 16/2012 supone la pieza central de la austeridad sanitaria, pero también implica una ruptura con consensos políticos existentes y un retorno a modelos de seguridad social. La caracterización de la austeridad sanitaria explora los impactos en el ahorro, en los servicios y en el modelo sanitario, aunque la información disponible sólo permite algunas consideraciones indicativas. Las conclusiones inciden en la necesidad de cambiar la senda de recortes lineales, acelerados y radicales, aportando un marco temporal para aplicar reformas en clave de sostenibilidad interna; a tal efecto se plantea la conveniencia de restaurar consensos políticos e institucionales, de enfatizar el trabajo en gestión clínica y la desinversión de servicios inapropiados (aproximación a la profesión médica y activación de su papel microgestor), y de crear los marcos de buen gobierno e innovación organizativa que den soporte a estas reformas estructurales. [EN] The economic and fiscal crisis of 2008 has erupted into the debate on the sustainability of health systems; some countries, such as Spain, have implemented strong policies of fiscal consolidation and austerity. The institutional framework and governance model of the national health system (NHS) after its devolution to regions in 2002 had significant weaknesses, which were not apparent in the rapid growth stage but which have been clearly visible since 2010. In this article, we describe the changes in government regulation from the national and NHS perspective: both general changes (clearly prompted by the economic authorities), and those more specifically addressed to healthcare. The Royal Decree-Law 16/2012 represents the centerpiece of austerity policies in healthcare but also implies a rupture with existing political consensus and a return to social security models. Our characterization of austerity in healthcare explores impacts on savings, services, and on the healthcare model itself, although the available information only allows some indications. The conclusions highlight the need to change the path of linear, rapid and radical budget cuts, providing a time-frame for implementing key reforms in terms of internal sustainability; to do so, it is appropriate to restore political and institutional consensus, to emphasize "clinical management" and divestment of inappropriate services (approach to the medical profession and its role as micro-manager), and to create frameworks of good governance and organizational innovations that support these structural reforms. Sí

El buen desempeño de servicios de salud de producción pública tiene importancia vital, más allá del sector salud. Se aborda su buen gobierno y gestión a partir del marco conceptual de los valores e ideas del buen gobierno y de la experiencia de países más ejemplares, como referente práctico de buen desempeño. Se parte de la gran complejidad de los servicios públicos de salud, por su carácter público y su naturaleza profesional, y se identifican siete nudos gordianos de los servicios públicos de salud en España e Iberoamérica. Del concepto de buen gobierno se toma su carácter de referente ético y normativo y su potencial para renovar y dinamizar el gobierno de lo público. Del análisis comparado de los servicios de salud de producción pública se extraen ocho características que contribuyen a su buen desempeño. Se concluye con una reflexión sobre la importancia de compensar la posible hostilidad corporativa y gremial a un impulso reformista del statu-quo con alianzas que refuercen la confianza pública y el contrato social entre profesionales y ciudadanos en torno a los valores de los sistemas públicos de salud. The good performance of publicly-produced health services is of vital importance, well beyond the health sector. Taking into account the great complexity of the health services in the public sector due both to their public and professional nature, we identify seven Gordian Knots as being responsible for the most frequent problems of publicly produced health services in Spain and Latin America. From the concept of good governance we take its character as a normative and ethical benchmark and its potential to renew and invigorate the government of the public sector. From comparative analysis of publicly-produced health services in the best performing countries, we extract eight characteristics which contribute significantly to good performance. A final reflection is on the relevance of the importance of offsetting the potential hostility to a reformist impulse of the status-quo with alliances that strengthen public trust and the social contract between health professionals and citizens based on the values of public health systems.