HealthManagement, Volume 12, Issue 5/2010

Overview of the Spanish Healthcare System

The Spanish National Healthcare System ("Instituto Nacional de la Salud"), founded on Spain's General Healthcare Act of 1986, guarantees universal coverage and free healthcare access to all Spanish nationals, regardless of economic situation or participation in the social security network.

In 1998 the Sistema Sanitario Público (public health service) brought in an official mandate for both doctors and patients outlining the service to which they are entitled, explained in the Carta de Derechos y Deberes (Charter of Rights and Obligations).


The national system has been decentralised since 2002, which has given the regional healthcare authorities the autonomy to plan, change and upgrade the infrastructure, leading to enormous development in the healthcare technology scenario, especially in the usage of information technology. The reforms, which regionalised the system, were implemented in order to provide greater and equal access to the population, thus avoiding the concentration of health services in urban areas. This has also improved response time and increased the participation of the target community in the development and management of the national healthcare system at regional and local levels.

The current system consists of three organisational levels:

1. Central (Organizacion de la Administracion Central) 
The Ministry of Health (Ministerio de Sanidad y Consumo), the state's central administration agency, is in charge of issuing health proposals, planning and implementing government health guidelines, and coordinating activities aimed at reducing the consumption of illegal drugs.

2. Autonomous Community (Organizacion Autonomica) 
Each of Spain's 17 Autonomous Communities (Comunidades Autonomas) is responsible for offering integrated health services to the regional population through the centers, services and establishments of that community.

3. Local (Areas de Salud)
The "areas de salud" are responsible for the unitary management of the health services offered at the level of the Autonomous Community and are defined by taking into account factors of demography, geography, climate, socioeconomics, employment, epidemiology and culture. To increase operability and efficiency, the "areas de salud" are subdivided into smaller units called "zonas basicas de salud". 

The Inter-territorial Board of the National Health System (CISNS) is responsible for the coordination, cooperation and liaison among the central and autonomous region public health administrations. The board is chaired by the National Ministry of Health and the members are the Regional Ministers. It approves the national catalogue of services that must be provided by all regional health services (cartera de servicios communes). The catalogue of is divided into sections including primary care, specialised care, supplemental care, and pharmacy.

Primary Healthcare Services

Primary Healthcare services are available within a 15-minute radius from any place of residence. The main facilities are the healthcare centres, staffed by multidisciplinary teams comprising of general practitioners, paediatricians, nurses and administrative staff, as well as, in some cases, social workers, midwives and physiotherapists. The principles of maximum accessibility and equity mean that community primary healthcare also provides home care, whenever necessary and also deal with health promotion and disease prevention.

Specialist care is provided in specialist care centres and hospitals in the form of outpatient and inpatient care. Patients having received specialist care and treatment are referred back to their primary healthcare doctor, who assumes responsibility for any necessary follow-up treatment and care, ensuring the provision of continuous care under equitable conditions, irrespective of the patient's place of residence and individual circumstances.

Private Healthcare

Private healthcare insurance for treatment at private hospitals and clinics is not widespread and mainly used to avoid the sometimes long waiting lists to see specialist doctors in the public healthcare system. Only 10 percent of the population has voluntary private insurance although some private services are contracted by the public sector. Only in Catalonia, due to historical reasons, there are a large number of non-profit, semi-public entities. Private healthcare companies often offer quicker service to patients but also valueadded services such as private rooms, express mailing of test results and keeping patients informed via email and SMS messages.

Funding the System

The Spanish healthcare system is principally funded through taxation. The country's total healthcare expenditure, amounts to 88,828 million euro, which accounts for 8.5 percent of the GDP. Public healthcare expenditure accounts for 6.1 percent of GDP and represents an expense per inhabitant of 1,421 euro. The central government provides financial support to each region based on population and demographic criteria.

Healthcare Resources

The National Health System has 2,914 health centres and 10,202 local clinics providing basic healthcare services to the local population. In 2009 there were 804 hospitals operating in Spain. The National Health System has 315 hospitals, equipped with 105,505 beds, and four Ministry of Defence's hospitals contributing with 995 beds. The remainder 465 hospitals are privately run and have 53,013 beds, which totals to 160,981 beds installed in Spain's hospitals. Public hospitals are generally much larger than private hospitals and deal with a much higher number of patients.

Excluding dialysis equipment, computerised axial tomography (CAT) is the most widespread high technology in hospitals and dependent facilities, with a total of 677 units and a ratio of 14.8 per million inhabitants. Magnetic resonance follows with 438 units and a ratio of 9.6 per million inhabitants. The number of mammography units dependent on hospitals totals 492. There are 4.7 physicians per 1,000 inhabitants and annually they attend to more than 273 million medical consultations per year in primary care. 

Healthcare Challenges

Spain has among the world's healthiest people with an average life expectancy of 81, one of the highest in the EU. The incidence of heart disease in Spain is among the lowest in the world, however, skin cancer is one of the highest.
Spain also takes a different view to rehabilitation, convalescence and terminal illness, leaving care in these cases usually to the relatives, meaning that are very few public nursing and retirement homes. This may prove one of the future challenges, as there is an increasing potential demand for social support services and benefits by the dependent population, and by carers.

However, one of the principle problems in Spain remains the limited coordination between the Autonomous Communities, which increases disparities in services and quality of care between the regions. Although the national system is overseen by the Ministry of Health and Consumer Affairs (Ministerio de Sanidad y Consumo) and coordinated by the Inter-territorial Board they focus more on long-term policies and cooperation and the responsibility of healthcare delivery lies with the individual regions.

Numerous projects to improve national cooperation have been implemented by the Spanish Ministry of Health such as the 'ep- SOS' (European patients Smart Open Services) pilot project, which aims to develop a practical framework and an ICT infrastructure that will enable secure access to patient health information, particularly with respect to basic patient summaries and ePrescriptions between different European healthcare systems. This should improve communication between Spanish regions and encourage cooperation.

The Spanish Presidency and E-Health

The Spanish Presidency of 2010 supported a fully integrated digital healthcare system in the post-2010 European Agenda and presented four strategic goals in healthcare, which aimed to:

  1. Introduce a global vision for an e-health policy, totally integrated in the post 2010 European Agenda; 
  2. Drive a new e-Health Action Plan, facing the new European challenges; 
  3. Develop and promote ministerial agreements, in particular regarding integration of e-health in community policy; and 
  4. Implement reinforced governance

In March 2010 two of the most important European events in the eHealth area took place: the High Level European Union Conference (EU) on e-health, and the World of Health IT (WoHIT) were bought together during the eHealth Week, which took place in Barcelona

The eHealth Week was a meeting organised within the Spanish presidency of the European Union (UE) in conjunction with the European Commission, the Ministry of Health and Social Policy, the Health Ministry of the Government of Catalonia, the TicSalut Foundation, and HIMSS Europe. It was an initiative of the Ministry of Health of the Government of Catalonia during which, meetings of the European health ministers and the European Forum of Regions in eHealth enabled European regions and Spanish autonomous communities to discuss the importance of ICTs for the health systems and the extent to which they have been introduced in their territories. During the four days of the eHealth week 2010, more than 160 renowned international figures brought in their experience and views in a total of 46 sessions in which they analysed the application of ICTs in the health systems from a variety of perspectives: political, economic, strategic, business and social.






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The Spanish National Healthcare System ("Instituto Nacional de la Salud"), founded on Spain's General Healthcare Act of 1986, guarantees universal coverag...

One comment

Miriam Pearson

Miriam Pearson

(2020-01-23 14:23)
Thank you for this very useful article. So I could leave Spain for several years, but as long as I kept my nationality/Spanish passport, return and use Instituto Nacional de la Salud without charge? If so, is there a limit on the number of years I can have been away? Any help with this would be greatly appreciated. Many thanks.

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