[Pay for performance in public directly managed healthcare centers. Part 2: The Spanish National Health System. SESPAS Report 2024]. / Evaluación del rendimiento y compensación en centros sanitarios de gestión directa. Parte 2: el Sistema Nacional de Salud. Informe SESPAS 2024.

In Spain, the compensation model for statutory health personnel is complex, heterogeneous, and more oriented to rewarding complementary functions and activities, than to paying for the actual performance in the position of employee. The various attempts to incorporate incentives have been distorted by a civil service egalitarianist culture, and weak systemic governance. External attractors (private practice, etc.) for healthcare professionals are becoming more important and neutralize many intramural incentives. There are few prospects of relevant or general changes, since the main actors involved are reforms-averse; but some environmental factors can lead to incremental improvements in employment contracts, in the information available to improve benchmarking, and in the creation of islands of good clinical governance and management. The economic scenario, increasingly concerned about inflationary trends and sustainability risks, may have a revitalizing effect of some governance and management reforms.

[Pay for performance in public directly managed healthcare centers. Part 1: General framework. SESPAS Report 2024]. / Evaluación del rendimiento y compensación en centros sanitarios de gestión directa. Parte 1: marco general. Informe SESPAS 2024.

Assessing and compensating performance in professional organizations is extremely difficult in direct public management settings of health services. Performance assessment is technically complex and, more so, with multiplicity of principals influencing goal setting. Incentives are a lever to generate directionality and motivation, both structural (for attracting and retaining workers) and specific ones (rewarding performance and directing behavior towards institutional goals). Incentives influence the behavior of workers in various ways, and their effectiveness seams weak and controversial in publicly run health services. To overcome the problems of deciding and evaluating performance, both good governance models and the revitalization of contractual management are required. To improve the effectiveness of incentive models, it is convenient to: 1) widen the conceptual framework of incentives, to incorporate the structural aspects of employment contract and payment; 2) improve the designs from a greater understanding of the determinants of motivation; and 3) broaden the lens to survey the extra-mural factors that alter the behavior of workers, trying to counter them.

[Contemporary relevance of the Spanish General Health Act after twenty five years]. / Vigencia de la Ley General de Sanidad tras veinticinco años.

Since its enactment in 1986, the General Health Law (Law 14/1986) has undergone several changes that have consolidated a model of National Health System. The law was embodied in 113 articles, ten Additional Provisions, five transitional arrangements, two Repeal and fifteen Final Provisions, has altogether 143 articles. After reviewing all legislation that appeared from 1986 to until today we can see that there are 106 articles (74.2%) that have lost regulatory effectiveness and merit analysis or reflection. All these items can be classified into four groups, the repealed and amended 26 articles (18.2%), 33 items of obsolete group (23.1%); the group of ill-developed are 6 articles (4.2%) and the critical (controversial and under ambiguous wording) group that has 41 articles (28.6%). After a quarter century of enforcement of the Act, two thirds of it to be reviewed. This legal weakness suggest the need of a new General Health Act for the Spanish National health System, being it a central objective of a political wide agreement.

[Identification and modulation of the systematic irrational behaviour in medicine and public health]. / Identificación y modulación del comportamiento sistemáticamente irracional en medicina y salud pública.

Several scientific disciplines are focused in the irrational behaviour of individuals. This predictably or systematic irrationality though violates the assumption of "maximising the expected utility", creates a new promising field of research and policy improvement. In this paper five dimensions in the distortion of preferences and decisions are reviewed, and some examples of policy initiatives for redressing and influencing the misled behaviour are provided. The "asymmetric policies for merit goods" have good foundations for future development of public health policy and practice.

[Asymmetric policies for merit-goods: harmonizing individual and social preferences in public health]. / Políticas tutelares asimétricas: conciliando preferencias individuales y sociales en salud pública.

Behavior is a major determinant of health, but changes in individual conduct are difficult, and health promotion lacks effectiveness. State intervention in the last century, rooted in the modernist movement, went far beyond dealing with externalities and built the framework of the welfare state. The crisis of the welfare state and post modernity after the 1970s led to a weakness of ideologies and values, narcissistic individualism, and lack of trust in institutions, all of which hampered the ability of society's perspective to influence individual behavior. A review of health economics (especially merit goods) and public health (ethics and values of health promotion and prevention) may be useful to understand certain dilemmas in the balance between public intervention and individual autonomy. Given that many unhealthy decisions come from biased or irrational individual preferences, a promising new field in public health interventions is being developed, known as <>, or, more appropriately, as <>, which allow society to selectively influence those individuals whose decision biases lead to self-harming behavior, without constraining the autonomy of well informed autonomous individuals (even though their preferences may not coincide with society's recommended preferences).