Governing for Care Integration: Evidence from Spain's Health and Social Care

Integrating health and social care is particularly challenging when responsibility is distributed across multiple levels of government and sectors, yet the governance conditions that enable or hinder integration remain poorly understood. Spain offers a valuable comparative setting: while its Autonomous Communities share a common national framework and hold responsibility for both health and social care, they have developed distinct governance models for integration.

We examine the multi-level governance of integrated health and social care drawing from evidence in Spain and using the TAPIC framework (Transparency, Accountability, Participation, Integrity and Policy Capacity) to identify barriers and enablers. This two-phase qualitative study covered six Autonomous Communities with established integrated care initiatives, combining six semi-structured interviews with senior regional leaders and three in-depth case studies based on document review and multi-stakeholder focus groups. Coding was deductive against TAPIC, attending throughout to how authority, resources and responsibilities are distributed across levels of government; a second, inductive stage, reported in the Methods, derived the CARE framework from the same dataset.

We found substantial variation across all TAPIC dimensions, with governance weaknesses arising primarily from relationships between levels of government rather than within individual tiers. Fragmented information systems and unclear cross-sector responsibilities undermined transparency and accountability, while participation often remained procedural and failed to meaningfully engage underserved groups. Integrity challenges stemmed from blurred organisational boundaries and ethical dilemmas surrounding resource allocation and data sharing. Policy capacity varied widely, ranging from regions with strong digital infrastructure to those reliant on voluntary resources. Building on these findings, we developed the CARE framework-Collaboration, Adaptation, Resource Use and Empowerment-which translates TAPIC's diagnostic insights into actionable governance functions.

Multi-level governance gaps, particularly around transparency, accountability and consequential participation, continue to constrain integrated health and social care in Spain. CARE offers a practical governance framework to support implementation by strengthening collaboration, adaptation, resource use and empowerment across sectors and levels, though it is derived from a single national context and requires validation elsewhere.