Juan Roca Guiseris, MD
President of Spanish Society Critical Care and Coronary Units (SEMICYUC)
Critical Care and Emergency Department Hospital Universitario Virgen de las Nieves, Granada, Spain
This article presents a description of the Spanish National Health System.
Spain: General Information
Spain occupies 505,182 km2 and had a population of 42,197,900 inhabitants in 2004 (Instituto Nacional de Estadística 2005). In 2004, Spain’s Gross Domestict Product (GDP) was $991,442 million, and its Gross National Income (GNI) per capita was $21,210 (World Bank 2005). The fertility rate in Spain is one of the lowest in the European Union (EU), although it recovered somewhat in 1993, reaching a rate of 1.3 children per woman (Instituto Nacional de Estadística 2005). In recent years, the aging of Spain’s population has decelerated, due to the arrival of foreign young people. The median age of the population is 40.2 years (40.99 for Spanish citizens and 32.82 for resident foreigners).
The classical indicators of health in Spain are among the best of the world. For example, in 2003, the life expectancy of Spanish men and women was 77.2 and 83.7 years respectively, which places Spanish women as the most long-lived in the EU. Spanish men occupy the second position, coming in just behind the Swedes (77.9 years).
In addition, in 1992, Spain reached the world lead for donation and transplant of organs. In 2003, there were 34 donors for every million inhabitants (Instituto Nacional de Estadística 2005).
The leading causes of death in Spain fit the profile of a developed country. The incidence of death from lung cancer, cardiovascular disease and work-related accidents is increasing, but deaths from infectious diseases and traffic-related accidents are down (European Observatory on Health Care Systems 2002).
Spanish National Health System History and Evolution:
Up to the arrival of democracy and the approval of the Spanish Constitution, Spain’s healthcare system was based on the model of Social Security. Today, the Constitution establishes the right of all Spanish citizens to the protection of health, and healthcare is provided through the National Health System.
The National Health System is decentralized, and in accordance with the General Law of Health, the public healthcare system is managed totally by Spain’s 17 autonomous community governments (Ley 14 1986). The National Health System shares the following fundamental characteristics of public health services in Europe:
• Belonging to the same insurance provider according to citizenship, rather than membership in a specific union (as in the case of social insurances).
• Financing primarily through taxes and not through social healthcare fees.
• Predominance of public health providers.
In Spain, 99% of the population has public health coverage through the obligatory national system. The comprehensiveness of the National Health System’s Catalogue of Services and the practical absence of co-payment (only required for pharmaceutical services) make our system one of the most generous in the EU (Jimenez 1997; Temes et al. 1992).
Healthcare financing and the provision of services are predominantly public. Approximately 71.2% of the health expense is public, with numbers very similar to those of other EU countries (OECD Health Data 2003). The total health expense in Spain is 7.7% of the GDP (versus 9% in the EU). The healthcare expenditure per capita in Spain is $1,835, whereas the average of the 15 member states of the EU is around $2,621. Nevertheless, the pharmaceutical expense in Spain is seven percentage points greater than in other EU countries (Organization for Economic Co-operation and Development 2005).
The organization of primary care in Spain is based on the Centers of Health (buildings or places where primary healthcare assistance is exercised) and in Teams of Primary Attention (multidisciplinary sets of professionals, fundamentally formed by doctors and nurses). The centers are public, and the healthcare professionals there are civil servants. This is atypical in Europe, where primary care is generally comprised of independent professionals who enter into a contract with the public system.
Primary healthcare benefits covered by the National Health System include medical and paediatric healthcare, prevention of disease, health promotion and rehabilitation. The main benefit historically excluded is dental care (Instituto Nacional de la Salud 1990).
Specialized inpatient and outpatient healthcare cover all medical and surgical specialties in acute care. Secondary care providers offer specialized surgical or medical consultations and hospital care and are charged with diagnosing and treating illnesses that, due to their complexity, cannot be addressed byprimary care providers. Secondary care in Spain is provided by hospitals. Prior to the healthcare reforms initiated in 1982, secondary care specialty centers often shared consultation space with primary care centers. Thus, specialty centers are often considered consultation centers external to the hospital in which they are located (Cuervo et al. 1994).
The coverage provided by the National Health System does not include social and community care. These services are partly managed by the Ministry of Labour and Social Affairs, and partly by the 17 autonomous communities. Local governments are also involved, especially in the planning and management of services. There are high co-payments for most social services.
The number of hospitals in Spain, according to the National Catalogue of Hospitals on December 31, 2005, is 779, with an average capacity of 202.8 beds. 59.05% of these hospitals are general hospitals, 14.5% are geriatric or long-term stay hospitals, and 11.8% are psychiatric hospitals (Ministerio de Sanidad y Consumo 2005). In 2003, there were 3.1 acute care beds for every 1.000 inhabitants (Organization for Economic Co-operation and Development 2005).
The number of doctors in Spain, according to information from the Instituto Nacional de Estadística (INE), was 194,668 in 2004, with a rate of 4.5 doctors per 1,000 inhabitants. This is the second largest number of doctors in Europe, after Italy. Almost 60% of Spain’s doctors are men, although if we restrict ourselves to doctors under 45 years old, 56% are women. The number of collegiate nurses is 225,487, with a rate of 5.2 nurses per 1,000 inhabitants. The percentage of women is 81.6% (Instituto Nacional de Estadística 2005).
The quality plan for the National Health System (Ministerio de Sanidad y Consumo 2006) offers six major areas of performance that try to answer the questions that affect the major principles and challenges of our healthcare system:
1. Protection and promotion of health and prevention of illness.
2. Encouragement of equity.
3. Support to human resources planning in the healthcare sector.
4. Realization of clinic excellence.
5. Use of information technologies to improve healthcare for Spanish citizens.
6. Increased transparency.