It is impossible to not appreciate the fierce sense of independence when traveling in the Basque Country. While I was fortunate to leave right before the brutal heat of the past month, it is clear that the somewhat tortured regional history of the last half century still influences much of the current narrative, and arguably this political history has influenced the healthcare framework now managing the 2.2 million residents of this beautiful but complicated region.
For the nearly four decades since the end of the Spanish Civil War in 1939 until the establishment of the Spanish Constitution in 1978, this region was a set of quite independently governed territories which suffered through considerable political turmoil. The Constitution provided for a much greater degree of home rule and autonomy but was overshadowed by the rise of the Euskadi Ta Askatasuna (ETA) separatist group. While the ETA was formed in 1959, the period between 1968 – 2010 saw significant terrorist activity with nearly 1,000 political killings. Since the permanent cease fire in 2011, the Basque Country has enjoyed relative stability and prosperity; GDP per capita is 33% greater than the rest of Spain and 40% above the average for the European Union.
Arguably the history of this region was most poignantly captured by Pablo Picasso’s Guernica masterpiece which famously portrayed the German bombing of that town in 1937.
With political stability came a concerted effort by the government to address what was increasingly becoming the next crisis – chronic disease for an aging population. Healthcare expenditures in Spain are approximately 10% of GDP and rising. In 2010, the government issued the “Strategy to Tackle the Challenge of Chronicity in Basque Country,” and while a mouthful, this manifesto reflected an effort to create a more effective and responsive healthcare infrastructure. Echoing the region’s history of independence, what emerged was a centralized set of operating principles but with significant flexibility to empower frontline healthcare workers.
The Basque Health Service is called Osakidetza (established in 1984) and is the public entity that organizes the 13 integrated health organizations and employs the 12,400 providers in region. Central to these initiatives is to encourage much greater care coordination, as well as use of in-home health and telehealth services. Analysts have compared this system to the Canadian healthcare system and have observed that most Medicaid programs in the U.S. do not have these levels of innovation and autonomy.
There were two other fascinating observations from the Basque Country. To the east, the Catalonia region also struggled with self-determination and how best to govern within the borders of Spain. While the Basque Country often suffered through violent unrest over those many decades, the Catalans were relatively content through that period, that is until the past few years when there has been significant separatist unrest. Recall the horrific Barcelona terrorist attacks in the summer 2017.
It was also quite surprising to learn that, while there are only 2.2 million residents in the Basque Country, the diaspora is vast. It is estimated that between 2.5 – 5.0 million Basques live in Chile alone. The largest cluster of Basques in the U.S. is in Boise, Idaho where the Basque Museum and Cultural Center is located. I never did learn why Boise.