Spain’s National Health System: Structure and Financing
Since 2002, the National Health System (NHS) in Spain has been managed by the Autonomous Communities. These communities are responsible for healthcare within their territories. The transfer of health funding was integrated into the common funding of each community through taxes, as outlined in Law 21/2001.
These transfers represent the most significant structural reform in the history of Spanish healthcare. The Autonomous Communities now have a large measure of autonomy to legislate, organize, and manage their health services.
Healthcare Financing in Spain
Spain spends relatively little on healthcare compared to other countries in the region. According to the OECD EU 15, only Portugal and Greece had lower public health expenditures than Spain.
Similar to other European countries, the Spanish Social Security Health Care system built a network of providers, including clinics and hospitals, which evolved into a large, integrated healthcare organization. In practice, the Health Services of the Autonomous Communities are an undifferentiated part of their autonomous government. While there have been significant legal changes, these have not affected the staff. This differs from the British and Scandinavian health services, which are organized and run separately from their governments.
Health Benefits and Access
The Spanish National Health System (SNHS) provides efficient and equitable access to most modern medical treatments, with few exceptions (such as dental care). However, the care of health services has not seen the same level of development and remains an area of severe deprivation, negatively impacting curative healthcare. The organization of health services into primary and specialty levels is a positive feature for quality and efficiency. Another important aspect is that patients in the SNHS do not have copayments for the use of services, except for 40% of medicines in pharmacies (pensioners and certain patients are exempt).
Organization of Healthcare in Spain
Article 56 of the General Law of Health defines health areas as:
“the fundamental structures of the healthcare system, responsible for the unified management of schools and establishments of the Health Service of the Autonomous Community in its territory and of the health services and health programs to be developed by them.”
Spanish public healthcare is organized according to the Autonomous Communities. Within these communities, health services are divided into territorial demarcations called Health Areas. Each area ideally serves a population of 200,000-250,000 people, and each province must have at least one Health Area. These areas organize and provide all health services for their population. Healthcare is also organized into two levels:
1. Primary Care
Primary care is centered around health centers and clinics. The general practitioner/family doctor is the professional reference and the gateway to all public health services. Every citizen has a general practitioner/family doctor, and each doctor is responsible for a list-serve population quota. Ideally, this quota is 1,500-2,000 people to ensure good care. However, these quotas vary depending on whether the area is urban or rural, and this is one of the most common complaints among the population and physicians.
Following the Primary Care reform of 1984, general practitioners/family doctors work as part of a Primary Care Team (EAP). This team includes nurses, administrative staff, social workers, and others. Support Units are also available, such as ER, mental health, physical therapy, and pediatrics. These are all part of the primary care level, along with emergency health services, which are covered in almost all Autonomous Communities (ambulances, specialized personnel, etc.).
2. Specialized Care
Specialized care is centered around the General Hospital. Patients can only access specialist doctors upon the advice of their family doctor. All hospitals have emergency departments that are open 24 hours a day and are a widely used resource for immediate attention.