A seed towards a sustainable food system in healthcare institutions: the case of the Basque Country

Figures & data

Figure 1. Location of the Basque Country in Europe, with the integrated health organizations (IHOs) spread along the Basque Autonomous Community.

Source: irekia.euskadi.eus, Basque Government.

A set of three images describing the geographical location of the Basque Autonomous Community within Europe, within the Basque Country, and a final image with the location of the IHOs spread along the provinces of Bizkaia, Gipuzkoa and Araba.

Figure 2. Methodological process of the case study.

A graphical scheme describing the four step methodological process applied in the present case study.

Figure 3. Main framework to instigate the process of sustainable food procurement strategy (SFPS) development.

A graphical scheme naming the main components of the framework to develop a SFPS, which includes healthy and sustainable food services; sustainable food supply systems; and a multi-level governance, all of which are crossed with some transversal characteristics to take into account while applying the SFPS.

Table 1. Participant profile, general characteristics.

Participant profile	Institution	Gender
Healthcare system personnel
Head of hospitality service	Osakidetza, Basque Public Health System	Female
Nurse		Female
Auxiliary in nursing care		Female
Dietitian		Female
Hospital chef		Male
Academia and technical profile from public institutions
Researcher	Universidad del País Vasco (UPV/EHU)	Male
Project officer	Elika Basque Foundation for Agro-Food Safety	Male
Project officer	HAZI Basque Foundation for Rural, Coastal and Food Development	Female
Agents related with food production
Director	Council of Agriculture and Ecological Food of the Basque Country	Male
Communication manager	Harakai Kooperatiba (livestock cooperative)	Male
Technician	EHNE Bizkaia (farmers’ union)	Female
Director	ENBA (farmers’ union)	Male
Other
Public health technician	San Sebastian–Donostia City Hall	Female
Dietitian	Freelance	Female

Table 2. Challenges and action plans to work towards sustainable food procurement strategies in the Basque Healthcare System.

Challenge	Action plan
Transversals
#1: Establish an initial diagnosis of each integrated health organization (IHO)	1. Assess the current situation of the hospital food chain and develop a global diagnosis of the hospital’s food environment. Based on this, establish improvement objectives: a) Periodic evaluations to assess changes, obtained benefits, etc. b) Quantification of the general volume of products, and the amount of those that are local (even if it is very few) c) Evaluate the uneaten menus, the leftovers d) Establish a common diagnostic methodology to be able to compare data
# 2: Awareness and training of healthcare workers and users	2. Awareness campaigns in the IHOs based on the diagnostic study of the situation of each IHO (challenge # 13): a) Aimed at different audiences (managers, workers, users) b) Essential to raise awareness among the ‘chiefs’, to encourage other professionals in the health organization c) Make decision-making power people aware of the real situation of the Basque food production system d) Staff awareness, since they are the ones who will carry out the food strategy. Educational and informational campaigns. Visualization of the problem e) Periodical training on healthy and sustainable eating. Adapted to the needs and the real situation of each IHO 3. Include sustainability in subjects within the University Health Degrees and related professional training 4. Information and campaigns for the general population. Offer dietary information. Involve the dietetic staff
Healthy and sustainable food services
# 3: Promote healthier and more sustainable menus	5. Review and update of menus, adjusting them to the real needs of the patients (flexibility considering patient’s profile, i.e., geriatric patient that cannot chew well, do not pass directly from basal to blended, perhaps work an intermediate menu) 6. Dietitians should reconnect with the food-producing sector to learn about topics such as seasonal produce, methods of production and their impacts, etc. and to pass this knowledge on to menu design
# 4: Coordinate (control) waste	7. Optimize procurement quantity and storage management 8. Greater control and coordination of the quantity cooked (minimize waste) 9. Coordination with wards (control of admissions and discharges) for an improved estimate of the number of menus to be served. This requires a more effective communication between dietitians, nurses, assistants and doctors 10. Evaluation of waste in different settings, considering the execution of actions explained above to reduce food waste
Sustainable food supply system
# 5: Prioritize sustainable food	11. Establish sustainable product definition criteria. Discuss and define what is sustainability, sustainable products, local products, ecological products, certified products (integrated production, PGI, etc.), family farming, producer groups, cooperatives, etc. 12. Promote and create producer associations
# 6: Sustainable food procurement strategy (SFPS) as a driver for local agricultural production	13. Adapt the tendering criteria towards sustainable food system criteria 14. Generate meeting points, relationships and knowledge exchange between food producers and IHOs
# 7: Promote the installation of young people in the primary sector	15. Children education, add value to the importance of food producers and the primary sector in general, as a source of health and sustainability. Inculcate food, health, production methods, etc. in the school curriculum 16. Evaluate the current primary sector installation policy, the accompaniment, the facilitation, etc. to design a more successful one 17. ‘Monitor’ young people interested in dedicating themselves to the first sector
# 8: Access to land, with adequate conditions	18. Evaluate the current land access policy and design a more successful one 19. Monitor non-productive agricultural land. Tax on agricultural land that is not used to produce food
# 9: Establish an initial diagnosis of the local production level	20. Generate a database of local producers, by categories. Whatever the capacity might be from the productive sector, this should not limit purchases from it
Multilevel governance
# 10: Create a multidisciplinary working group for governance and leadership, with binding capacity	21. Share values and be clear about definitions: healthy food, sustainable food 22. Include the primary sector in the working group 23. Identify resources: people, time, capacities, budget, etc. The group should set both short- and long-term objectives and their organizational structure
# 11: The institution is responsible for easy access to healthy and sustainable food	24. Promote healthy and sustainable food in all hospital settings: patients, equipment, cafeteria, vending, etc.
# 12: Work the legal framework	25. Creation of lobbies to change the legal framework (the ecological movement in Europe is given as an example) 26. Observatory of regulatory experiences in other regions, countries, etc. focused on sustainable, healthy and safe food 27. Insertion of dietitians and nutritionists in Osakidetza (Basque Healthcare System), qualifying them to deal directly with the patients in wards and to be part of the medical team, in order to establish the correct dietary treatment
# 13: Value the organic and sustainable food	28. Prioritize organic food and local food in tenders. Assess local food suppliers’ capacity. The two realities of the needs of the organization and the capacity of the providers should come together
# 14: Criteria for tenders with a sustainable vision	29. Currently, economic criteria prevail over sustainability. Life cycle analysis, i.e., the relation between quality and cost, should be considered 30. Establish a requirement in tendering document that divides the products into smaller lots, so that different suppliers can be awarded. Pressure the intermediaries/suppliers to adapt to smaller lots