Module 11 Social Innovation and Entrepreneurship Joan Ubach

Dr. Katherine Milligan

Background:

Spain has undergone a strong demographic change, with the countryside losing up to 28% of its
population over the past 50 years , this despite the external legal and illegal immigration, which has
reduced this demographic shift. The hardship of the conditions, as well as the limited access to services
has coined in the popular language the name of “la España Vacia” or the empty Spain.

The migration from rural environments to the urban areas is creating may collateral impacts to the
remaining rural population, for example the loss of economic activity and population lead to reduced
investments and tertiary sector services, this regions given the low population density, a continuous loss
of their traditional industries and a continuous degradation of their economical ecosystem, investments
in the area of public or private entities are reduced, and furthermore an increasing income gap that
accentuates the migration driving forces.

Although the economical degradation of an area is already detrimental for fragile economy like Spain
the consequences go further beyond when we observe the impacted local communities.

➔ Lack of economic activity (specially for youth) making it difficult for people to earn their living.
➔ Isolation and lack of services.
➔ Aging population.
➔ Institutional abandonment
➔ Vicious circle of decline

Problem Statement:

How to improve in a sustainable way, sufficient access to basic services (health, care, and wellbeing)
to elders in remote and rural areas of Spain.

Problem description:

Spain has undergone a strong rural to urban migration. Statistics show that this migration is above
European average (0.1%) compared to Spain rural areas that are dropping at an average annual rate of
0.7%, with communities that they are dropping yearly up to 1.4%.

When analyzing more deeply, we can observe that the migration phenomena is mainly driven by the
population segment from 20 to 64 years that move out to of the rural areas, looking for a more stable
work opportunity or to continue in their development.
Module 11 Social Innovation and Entrepreneurship Joan Ubach
Dr. Katherine Milligan

This population shift is creation a strong increase of the percentual fraction above 65 years in the that
they are at the end of their professional career, with a receding income, active live and social or
economic capacity linked to the age of retirement.

Main impacted groups.

Elderly population (above 65): This age group is inevitably seeing their capabilities being reduced
progressively due to ageing. They are also confronted to obsolete or closing services, and a more
difficult access to social groups, services, healthcare facilities, or specialized care at an acceptable
distance and cost. This leads among others to an inefficient health system required to ensure a minimum
living standard.

Shop owners or services providers: a continuous decreasing of population in these rural areas
cumulated to the natural population decrease due to natural dead and low birthdate. This reduces yearly,
the benefits generated and the business performance as well as the owner net income. Leading shop
owners to close their business, delocalize them or mobilize to more densified areas.

Local institutions: This migration progressively reduces the attractivity for new business to implement
(restaurants, grocery shops, bakeries, hairdressers…) or even banks, basic health care institutions, or
elderly facilities like retirement homes. This services reduction causes a cycle of degradation, where a
lack of users or customers reduces the performance, interest or quality of a product or service, making
it less interesting compared to other areas and therefore, further reducing the offering, driving
population that can potentially enrich the economical network to move out. Ultimately this lack of
interest removes tremendously the power of the local institutions to act, take measures, and turnaround
the situation.

Youth or young professionals: In the current situation the young population that could eventually
create the driving force for change, face similar challenges with the needs associated to their state of
life: Child schooling, education, pediatrics, variety and quality of leisure, cultural activities, mobility,
employability, remuneration, or even access to services like restaurants requires enormous efforts.
Forcing this fraction of the population to migrate to zones where these basic needs are fulfilled.

Medical professionals: Currently it is estimatated that a total of 10.000 medical profesionas at all
levels are dedicated for the rural areals in spain for a population of 7.5 million people.

This Medical professionals are confronted to the same lack of resources services, and a strong
frustration given the obsolescence of the equipment, the thinness of the means, and the ostracism of
being located in isolated areas.
Module 11 Social Innovation and Entrepreneurship Joan Ubach
Dr. Katherine Milligan

Problem categorization:

When evaluating the problem of rural migration and the medical service to elders in the complicated-
Complex spectrum, it leans more towards the complex side. The magnitude of the gap and the self-
ignited vicious cycle of decline creates a continuous degradation that accelerates on pace. The system
dimension of the problem with the multiple age groups and the different effects that impact each of
them, together enhance migration, decisions to stop or shift business, and ultimately the quality of
services provided, can have long term or immediate dramatic impacts on the society (in this case,
focusing on the elders’ impact). Solving it will require modifying and transforming elements of the
system, changing the existing patterns to ensure the right positive chain effect. With the objective to
shift and heal the situation in a long-term horizon.

Additionally given the spread and surface of the rural areas, and each specificity (social and cultural)
from each rural area, and the distance to the closest urban area makes it impossible to find a one fit for
all solution.

Out of this substantial number of factors and variables that compose the system, I will focus on the ones
that affect the elderly health system in rural areas and neighboring or most impacting factors.
Module 11 Social Innovation and Entrepreneurship Joan Ubach
Dr. Katherine Milligan

When crossing the different problem spaces with the conditions of system change:

Technical problems Economic barriers

Limited assets or Savings (Resource Flows)

The elderly rural population in Spain holds a strong traditional mindset, where the women stay home
taking care of the kids, and taking care of the house, while the man brings the sole income. This mindset
has been aggravated by a lower contribution to the pension funds given the systematic culture of “dinero
negro” (off the books). This situation still remains, but currently, it has left a major part of this elderly
population with few savings and the minimum retirement rent granted by the state.

In these rural areas, growing their food and vegetables is one of the channels to minimize expenses,
nevertheless, as aging goes, and physical conditions deteriorate the capacity to self-grow food, gets
reduced. The

Strong extended family mindset and the “secured rent” has given during the economic crisis a status of
privileged remunerated population, when unemployment in youth rose 40-50%. It was not a surprise
that this rent and the yearlong savings was the sole income to supported entire families’ structures
during the economic crisis. This resources consumption during the time of crisis create a strong
incertitude, where elders have erased any past option to go to an elderly care center or having
discretional expenses to improve their health, or even afford transport costs to access consultations, or
even private, semiprivate treatments.
Module 11 Social Innovation and Entrepreneurship Joan Ubach
Dr. Katherine Milligan

Lack of infrastructure: (Resource Flows)

Rural areas are insufficiently connected. Former transport structures are obsolete, decommissioned, or
strongly reduced or underperforming, given the usage, cost of exploitation and maintenance. Access to
the nearest urban area with a sufficient medical structure service, or expertise via public transport means
(if exists) require most of the times very time constrained traveling times and slots, long uncomfortable
trips at and inefficient connections. In their absence, taxi solutions and sleep over needs strongly
increase the costs of medical consultations. In these rural areas basic infrastructures and needs, like
potable water and electricity, exist, on the other hand, new basic infrastructures (internet, mobile
network) are strongly underemployed isolating further the communities, or making it impossible
telemedicine or remote consultation options.

The level of isolation of some communities, is such that there is no possible response to an emergency
required an ambulance in the due time (i.e., in the case of a heart attack)

No market access: (Practices)

In the majority of cases, basic medical services have been closed or consolidated into CAPs (centers of
primary attention) that spread their reach over perimeters above 60 Km. When we look at access at the
highest end diagnostic or treatment facilities, we are confronted into distances that rage 100-200Km.

These medicalized centers have medical doctors that rotate their services within different areas and with
an access frequency of 1-2 times every two weeks. These medical centers are highly appreciated since
it is the unique source of medical counsel at a sufficient proximity reach. Nevertheless, it is highly
insufficient in case of illnesses that have a fast evolution (specially with fragilized patients)

Lack of essential products and services: (Resource Flows)

Services and products like a pharmacy or a para-pharmacy are key to ensure the access to the minimum

Medicines in these rural areas, the high distances, or access to this business, creates difficult access to
medication, as well as a stocking and expiration effect of medicines, with the undesired side effects that
this can cause. Other dimensions like basic grocery shops dimensions have reduced stock, products or
even supplies limiting the possibility to a varied and healthy nutrition or adapted healthcare products.

This lack of essential products anchors the community’s growth, an enhances migrations, just as an
example, in multiple rural villages do not have grocery shops, and the surrounding grocery shops do
not have infant products (infant formula, pampers… since there are no customers) and it is necessary
Module 11 Social Innovation and Entrepreneurship Joan Ubach
Dr. Katherine Milligan

to drive above 60 km to purchase them this situation does not favor truism or young families to settle
in this areas. This is not taking in consideration more sophisticated products or services.

This lack of essential services like High speed and quality internet, difficult the access to remote
solutions, but as well as to the implementation of nomad population looking for low-cost locations
(digital nomads or people working remotely)

Technical problems - Cognitive barriers:

Low problem awareness: (Mental Model)

The elderly population in these rural areas can be categorized in two different segments.

Legacy habitants: These persons have spent most of their life in this area and have hardly moved out
travelled or been exposed to any type of external influence. Their level of education is low, (basic
education) and they had integrated the labor market in the primary sectors young in their life. This
combination anchors them in these rural areas. They perceive interacting and mixing with other non-
rural or non-rural individuals as an extremely challenging an unpleasant situation. They can also
perceive foreigners as enemies and invaders that they do not have any legitimacy on this area.

Seasonal habitants: This elderly (or other) come seasonally and punctually to the rural areas since they
have a personal attachment, a house or apartment in the region, most of them had migrated in the past,
the have higher cognitive capacities, and they observe the impact of the rural area as a degradation, and
how impacts their direct comfort, or the hardship when they are there. The cycle of continuous
degradation pushes also out these seasonal habitats, as their capacity to manage traveling and cope with
discomfort increases.

Lack of trust and opportunities not perceived: (Mental Model)

The habitants of this zones perceive the area where they live as the only temple and asset they have
almost as if it was a sacred area. They are extremely cautious to sell or allow the development or
integration of newcomers out of the inner village circle or even being owners of it

It is highly common that landowners will prefer to sell land for building habitats or to cultivate, to
persons that are legacy inhabitants at a lower price, than to sell it to foreigners or to people that had
migrated in the past that can offer a higher price. This impact is twofold, it does not allow the area
development and population increase, and at the same time creates an unwelcome and unhealthy climate
that does not allow to bring youth or develop business, increasing the driving forces for migration.
Module 11 Social Innovation and Entrepreneurship Joan Ubach
Dr. Katherine Milligan

Opportunities not perceived: the scientific literacy o technology capabilities, are extremely low or
inexistent. There is a strong mindset anchored in traditional medicine, this has an influence in the facility
or the speed that people will decide to mobilize and seek a specialized medical treatment. That cannot
be healed with herbs or habits, risking the right diagnostic and treatment.

Relational problems /needs Normative barriers

Structural Cast: (Power dynamics)

Although there is no structural cast as it can be perceived in the Indian casts. There is a strong powerful
heritage of strong families. This strong families have accumulated power and assets over generations
(land, financial power, structure, political power, influences)

The combination of the power, economic influences create an individualistic interest to maintain the
power anchored in this families. Any type of infrastructural development must have them considered
as stakeholders, and the “preferential vote” of being a controller or a decider on the suitability for their
interest can have a strong impact on how it will be implemented or the likelihood of being successful.

Traditional customs: (Mental Model)

In the rural traditional Spain, there is a strong legacy of family, elders are strongly attached to the land.
It is important to understand that in this rural communities, a vast majority of the inhabitants have a
legacy of 5 to 6 generation that were born, passed away, and buried within a radius of 20 km from where
they live. This is the origin where it comes the willingness to remain there, despite of the hardship, as
their parents and grandparents did. Even if this represents a sacrifice in their quality of life or reducing
their life expectancy.

Other Traditional customs like traditional medicine as mentioned before can palliate the impact of non-
critical illnesses, nevertheless they are counterproductive in the early identification of serious ones.
Creating a strong delay in between medical diagnostic and treatment.

Relational Problems /Needs -Political barriers:

Private objection of powerful forces (Power dynamics) (Relationships & connections)

The dispersity of rural health centers creates a strong tension in between the frequency and the quality
of services or products provided and the usage. This can apply to most economical fields, strongly
reducing the interest of any non-governmental organization to implement themselves in these rural
Module 11 Social Innovation and Entrepreneurship Joan Ubach
Dr. Katherine Milligan

areas. This lack of economic interest redirected investment to big urban zones, complexifies the
improvement of this areas.

Politically the electoral density and the impact on the elections does not justify strong pollical projects
to be urgently implemented since is a population without an electoral interest to leverage rural interest
in the promising side, but not in the execution side. This situation even difficult the creation of public
private partnerships that can improve the areas.

Political interest tends to defend the increase of population in the urban areas to increase the tax income,
the political power, and improving the costs service / capita costs in the name of efficiency performance
and optimal resources management.

This detrimental effect is normally not deliberate on the purpose of pejorating the situation in rural
areas, but instead to be perceived as good administrators of the public services and having the right
prioritization skills.

Individual agendas, on the political spectrum can be also a driver to benefit the biggest pole of votes in
the urban areas.

Inefficient or discriminatory policies (Policies)

This communities are affected to the inefficiencies linked to the scale effect the distance to urban
centers, representing a big challenge when operating a business, (where the current fixed and variable
costs get day by day more challenging). Or even the challenges to improve the infrastructure in public
investments, that are confronted to higher cost factors or premiums than other urban areas. where the
lack of basic economic infrastructure, increases the cost of implementing any type of improvement at a
comparable to urban areas cost.

Additionally, any medical or elderly treatment area needs to comply with all current applicable
regulations, therefore any increase or improvements on the existing infrastructure is affected by this
compliance extra costs increasing the complexity and viability of the project execution. This compliance
constraints cuts the potential benefits to have an incremental benefit to the society.

Another perspective is the discrimination in terms of qualified workforce. When we analyze the
situation of practitioners that would be interesting for any proximity purposes to join and work in these
areas, they are facing a sensible cut on their standard of living as well as inexistent or few benefits to
help them stablish in these rural areas.
Module 11 Social Innovation and Entrepreneurship Joan Ubach
Dr. Katherine Milligan

Key insights

➔ There is a fundamental infrastructure problem that is one of the driving forces of rural to urban
migration, enhanced by a lack of political and economic will and engagement to improve it.
➔ Elders are strongly attached to their land and their heritage and are strongly unwilling to let it
go, they prefer to compromise on their health than on their heritage
➔ There is a strong tension in between the economic performance of a service and the minimum
social service that rural areas should be provided.
➔ Digital, remote, or telemedicine require an infrastructure level and skills knowledge level that
is out of reach from the rural population within the focus group.
➔ Focusing in improving health delivery is set to fail since the global migration trend should be
shifted, creating a system shift, that adds value to the whole pyramid, of ages, and all
stakeholders making changes structural and self-sustainable.
➔ Elders have strongly compromised their future and wellbeing by supporting and sustaining
younger generation needs through the crisis.

Satelite view of the Population view showing the concentrated urban areas versus the rural areas.
Module 11 Social Innovation and Entrepreneurship Joan Ubach
Dr. Katherine Milligan

Anex 1: Population density in spain

Population Density (habitants / Km2) 2018 (source Wikipédia)

Anex 2 : 4 hours Public transport reach access from different cities in the rural areas.
Module 11 Social Innovation and Entrepreneurship Joan Ubach
Dr. Katherine Milligan

Bibliography
- Spain Battles Rural Depopulation (voanews.com)
- https://www.chronotrains.com/
- Estabilidad, formación y rescatar la Casa del Médico: cómo solventar la falta de
médicos en las zonas rurales - España vaciada - COPE
- ASAMBLEA VOCALIA ATENCION PRIMARIA RURAL (medicosypacientes.com)
- https://www.lamoncloa.gob.es/serviciosdeprensa/notasprensa/agricultura/Paginas/
2021/271221-areas-rurales.aspx
- https://elpais.com/espana/2021-09-18/la-juventud-migrante-renueva-la-espana-
rural-despoblada.html
- https://www.lavanguardia.com/vida/20230621/9057252/unica-alternativa-espana-
vaciada-inmigracion-funcionar-todas-partes.html
- https://www.realinstitutoelcano.org/documento-de-trabajo/el-impacto-
demografico-de-la-inmigracion-en-la-espana-rural-despoblada/
- https://www.semfyc.es/secciones-y-grupos/grupos-de-trabajo/medicina-rural/
- https://mirial.es/blog/estudiante-medicina/103-medicina-rural-el-medico-del-pueblo