CESM demands that Health stop managing the health crisis in Ceuta “from Madrid” and visit the centers

At this moment, there is no reform under processing in the General Courts or in the Assembly of Ceuta that changes the healthcare management model of the city (for example, through a transfer of healthcare competences from INGESA to the Autonomous City). Parliamentary activity related to Ceuta focuses on debates, motions, and non-legislative proposals about strengthening resources, working conditions, and response to the current migration crisis, but without a concrete normative initiative for competence transfer.

1. Competence framework: state healthcare via INGESA

Context documents confirm that, unlike autonomous communities, in Ceuta healthcare competences remain in the hands of the Ministry of Health through the National Institute of Health Management (INGESA). The central government reminds that the Autonomous City only has functions of administration, inspection, and sanction in public health, while INGESA “manages healthcare services in the scope of Ceuta and Melilla” (ConSalud, 07/04/2024).

The same analysis emphasizes that, unlike Melilla, the local government of Ceuta “rules out any formula to assume such competences” and “aspires to remain in the same status quo” while waiting for INGESA and the Ministry to improve the care situation.

2. Relevant state legislative initiatives

Among the state parliamentary initiatives, there are various general health laws approved or under processing (creation of the State Public Health Agency, law on alcohol in minors, neonatal screening, etc.), which mention Ceuta and Melilla as part of the National Health System and include them in state plans and networks. However:

• No specific bill or legislative proposal has been found to modify the distribution of healthcare competences in Ceuta.
• Nor does a law for “healthcare transfer” to the Autonomous City appear, analogous to those explored for immigration in Catalonia or healthcare in Melilla.

What is recorded in the Senate is a motion from the Popular Group to promote a healthcare management assignment with the Government of Melilla, but the journalistic analysis of that piece highlights that this route refers to Melilla and that in Ceuta the official option remains to demand improvements within the current INGESA framework (ConSalud).

3. Political and parliamentary debate on healthcare in Ceuta

In the state parliamentary venue, Ceuta appears recurrently as “ground zero” of the problems of the direct management model by INGESA. In a Senate debate, the Government defended that since 2018 there are more professionals, investments, and better equipment in Ceuta and Melilla, while the PP denounced a “national health emergency” with waiting lists and lack of specialists (ConSalud, 03/18/2025).

In the context of the severe migration crisis of summer 2026, new initiatives have been registered:

• The PP demands that Ceuta be recognized as a “hard-to-cover zone” and that the corresponding royal decree be fully applied, linking it to a “health system at the limit” and staff shortages (Redacción Médica, 08/12/2026).
• Vox has presented a non-legislative proposal in the Health Commission for Morocco to assume part of the healthcare and security expenses and to urgently reinforce INGESA services in Ceuta (referred by Demócrata).
• From the Government, INGESA and the Ministry insist that ordinary activity is maintained, that staff has grown around 8–12% since 2020, and that INGESA’s budget has increased by 70% since 2018, rejecting the term “health catastrophe” (InfoSalus, InfoSalus).

These initiatives are mostly motions or non-legislative proposals: they politically guide and feed the debate but do not themselves alter the distribution of competences or the legal management framework.

4. Role of the Assembly of Ceuta and local actors

At the autonomous-local level, the official bulletins of the City record sectoral agreements (social aid, oral health programs, subsidies, etc.), but no structural reforms of the healthcare model nor own regulations for the organization of the care system that imply assuming full management.

The main pressure vectors to “improve management” today come from medical unions and the Medical Association, which denounce chronic staff shortages and demand structural measures and specific incentives. CESM, for example, has requested the dismissal of INGESA officials for “masking reality” and has reiterated that Ceuta’s healthcare lives a “critical” situation without significant changes in governance having materialized yet (ConSalud, 01/08/2025).

5. Conclusion on the processing

With the available information, the situation can be summarized as follows:

• There is no specific law or reform under processing that transfers healthcare management of Ceuta to the Autonomous City or alters its basic management model by INGESA.
• There is intense political and parliamentary debate about resources, staff, incentives, and response to migration crises, channeled through motions and non-legislative proposals in Congress and Senate.
• At the local level, the City of Ceuta officially maintains the option to remain under state management, focusing its demands on the Ministry and INGESA to strengthen means and planning.

Therefore, rather than a structural reform in an advanced processing phase, what exists today is an open political conflict about how healthcare in Ceuta should be managed within the current competence framework.

In the autonomous cities of Ceuta and Melilla, healthcare has a special configuration: the Ministry of Health, through the National Institute of Health Management (INGESA), directly manages public healthcare assistance (which in the communities is done by each autonomous health service), while the cities themselves exercise competences in health and hygiene and the State maintains its basic competences of coordination and external health.

1. General framework of competence distribution

The starting point is the Constitution, which reserves to the State the exclusive competence over external health, bases and general coordination of health, and legislation on pharmaceutical products (art. 149.1.16 CE). From there, the Statutes of Autonomy of Ceuta and Melilla (Organic Laws 1/1995 and 2/1995) attribute to each city competence in “health and hygiene” within their territory, along with other functions linked to health protection at the local level.

The Law 14/1986, General Health Law, and especially the Law 16/2003, on cohesion and quality of the National Health System (SNS), complete the scheme. The latter establishes that references it makes to the competences of autonomous communities are understood to be made to the State regarding Ceuta and Melilla, “without prejudice to the competences of said cities”. That is, the Ministry of Health assumes the role that in the rest of the territory the autonomous health services have, but coexisting with the own municipal/autonomous competences of the cities.

2. Direct management of healthcare assistance by the State (INGESA)

The Royal Decree 118/2023, which regulates the organization and functioning of INGESA, specifies the functions of this body, attached to the Ministry of Health. Among its competences, the key article states:

• Management of healthcare services in the scope of the cities of Ceuta and Melilla, and any other activities necessary for the normal functioning of their services.
• Direction of the Healthcare Managements and Territorial Directions of Ceuta and Melilla, which organize hospitals, health centers, and other SNS devices in both cities.
• Cross-cutting functions for the entire SNS (centralized purchases of medicines and health products, management of the strategic reserve of products for health emergencies, etc.), which also affect Ceuta and Melilla.

In summary, in Ceuta and Melilla the Ministry of Health–INGESA acts as the “autonomous health service”, directly managing the care network of the National Health System: primary care, hospital care, emergencies, etc.

3. Own competences of the cities of Ceuta and Melilla

The Statutes of Autonomy attribute to both cities competences in health and hygiene (art. 21.1.19 LO 1/1995 –Ceuta– and equivalent provision in LO 2/1995 –Melilla–). On that basis, the royal decrees of transfer of functions in health matters: RD 32/1999 (Ceuta) and RD 1515/2005 (Melilla), detail that the cities assume, among others, functions of:

• Health control of drinking water, wastewater, bathing waters, solid waste, and air pollution.
• Health surveillance of housing, premises, and public or collective coexistence buildings.
• Application of the Regulation of annoying, unhealthy, harmful, and dangerous activities, in terms of environmental health.
• Mortuary health police.
• Authorization and control of centers, services, and health establishments within their competence (including pharmacies and other regulated centers).
• Study, surveillance, and epidemiological analysis and health promotion and protection programs in their territory.

These are competences of public health and environmental health control, closer to municipal/autonomous level, while curative healthcare mainly falls on INGESA.

4. Coordination, planning, and financing

Law 16/2003 on cohesion and quality of the SNS establishes that policies of health cohesion and correction of inequalities (for example, through the Health Cohesion Fund) are managed by the Ministry of Health. That fund and other state instruments finance:

• Care for displaced patients and reference services when it is necessary to leave Ceuta or Melilla.
• Comprehensive health plans and SNS strategies whose deployment in Ceuta and Melilla is often channeled “through INGESA”.

Additionally, the Ministry participates, along with the rest of the communities, in coordination bodies such as the Interterritorial Council of the SNS. Regarding what the law attributes to autonomous health services, in the case of Ceuta and Melilla those competences are understood to be exercised by the State health administration, that is, by the Ministry/INGESA.

Overall, it can be said that in Ceuta and Melilla the Ministry of Health has a dual function: on one hand, that of direct manager of public healthcare assistance (through INGESA), and on the other, that of state authority of bases, coordination, and cohesion of the National Health System, complemented with the competences of public health and environmental health of the autonomous cities themselves.

In Spain, the activation of special devices and reinforcement of healthcare services (including INGESA in Ceuta and Melilla) in crises is supported by a core of regulations: the Organic Law 3/1986 on special measures in public health matters, the Law 33/2011 General Public Health Law, the Law 17/2015 of the National Civil Protection System, the Law 2/2021 on COVID‑19, and the State General Emergency Plan of Civil Protection (PLEGEM) approved in 2020 (Resolution of December 16, 2020, BOE‑A‑2020‑16349).

1. Declaration of crisis or emergency situation

A state of alarm is not always necessary: many actions are based on ordinary competences of public health and civil protection.

• Reinforced “ordinary” health measures: LO 3/1986 allows health authorities to adopt, in the face of “urgent or necessary health reasons”, measures of recognition, treatment, hospitalization, or control, as well as those “considered necessary” to control communicable diseases, regarding patients, contacts, and immediate environment.
• National interest civil protection emergencies: Law 17/2015 regulates the declaration of civil protection emergencies and “national interest emergencies”. The PLEGEM (BOE‑A‑2020‑16349) establishes that, once this situation is declared, a state organic-functional framework is activated to mobilize resources from all administrations, including health.
• Prolonged health crises (COVID‑19 case): Law 2/2021 articulated a specific regime of prevention, containment, and coordination measures against COVID‑19 and was the legal support for many special health devices until their progressive deactivation by Order SND/726/2023 (BOE‑A‑2023‑15552).

2. Competences and specific role of INGESA

The general framework of health organization and coordination derives from Law 33/2011 and, complementarily, from Law 16/2003 on SNS cohesion (partially modified by Law 33/2011).

• Ministry of Health: according to Law 33/2011 assumes the high direction of state public health, coordination of the National Health System, and functions of external health (Order SND/84/2023, BOE‑A‑2023‑2723). In crises, it can issue orders of state scope, set criteria for resource use, and coordinate the autonomous communities.
• Autonomous communities: exercise, in their territory, competences of healthcare service provision and public health, activate health emergency and civil protection plans, and can adopt reinforced measures under LO 3/1986 and Law 33/2011.
• INGESA: heir of INSALUD in Ceuta and Melilla, depends directly on the State (royal decrees of transfer to the autonomous communities leave Ceuta and Melilla under state management). In crises, the Ministry can reinforce staff, material means, and care devices of INGESA as part of SNS measures, in coordination with Civil Protection when the emergency is of national interest.

3. Formal requirements to activate special devices

The regulations do not impose a single “ritual” for all cases, but do require certain formal minimums:

• Express act of the competent authority:
  • In public health: agreement, resolution, or order of the health authority (state or autonomous) that justifies the existence of urgency or necessity (LO 3/1986) and describes the measures (opening of extraordinary devices, reinforcement of human resources, referrals, etc.).
  • In civil protection: agreement of the competent body (e.g., Council of Ministers for national interest emergencies) that activates the PLEGEM or the corresponding special plans, in accordance with Law 17/2015.
• Technical justification: Although not always expressly cited in the law, the practice of PLEGEM and Law 17/2015 requires basing the activation on technical reports from civil protection and public health services that prove the risk, its magnitude, and the need to mobilize extraordinary resources.
• Activation of plans:
  • At the state level: activation of levels of the PLEGEM and specific state plans (e.g., plans against determined risks) that integrate the autonomous communities and the Cities of Ceuta and Melilla (BOE‑A‑2020‑16349).
  • At the autonomous level: activation of territorial civil protection plans and health emergency plans, which deploy special devices (field hospitals, emergency reinforcements, etc.).
• Official publication:
  • State-level agreements and general regulations: publication in the BOE (such as Order INT/399/2025 declaring national interest emergency, BOE‑A‑2025‑8486, or the cited Order SND/726/2023).
  • Autonomous provisions: publication in the official bulletin of the community for general effectiveness.
• Inter-administrative coordination: Law 17/2015 and PLEGEM require articulating coordination centers (state and autonomous) and management committees integrating Interior, Health, INGESA, emergency services, and other administrations, ensuring efficient and solidarity use of health resources.

In summary, to activate special devices and reinforce services like INGESA, it requires: a formally adopted and justified decision by the competent authority; support in technical risk reports; activation of civil protection and health plans (PLEGEM and autonomous plans); and publication and coordination through the mechanisms provided in Law 17/2015, Law 33/2011, and, when appropriate, Law 2/2021 or other special regulations.