Overview

The decentralised national health system is virtually universal, and provision is free of charge at the point of care

In Spain’s national health system (Sistema Nacional de Salud, SNS) coverage is virtually universal, mainly funded from taxes, and care is predominantly provided within the public sector and free of charge at the point of delivery. Opting out from SNS coverage is not allowed, although the population can buy voluntary health insurance (VHI) in addition to the public coverage. Health competences are transferred to the regions (known as ‘autonomous communities’), while the Ministry of Health is responsible for the overall coordination of the SNS.

Protection mechanisms are in place to support the financial protection of the population

Health spending has seen a large increase as a percentage of GDP, following the COVID-19 pandemic in 2020, with public expenditure representing 71.7% of the total expenditure on health in 2021. The benefits package is comprehensive and while cost-sharing is required for pharmaceuticals and some prostheses, out-of-pocket payments do not result in catastrophic spending for households. Co-payments have been largely reformed with further exemptions in place since 2020.

Latest reforms are directed towards maintaining the universality of the national health system, as well as promoting equity and cohesion

Recent major health reforms in Spain have focused on addressing the scope, breadth and depth of SNS coverage, with special emphasis on vulnerable groups. Since 2018, the basis for entitlement has returned to the condition of residency following new legislation on universal access to the SNS, and reversing a previous policy, by which eligibility was linked to the legal and employment status of individuals. Two draft laws aimed at strengthening the universality and equal access of the SNS are currently before Parliament. Future challenges to ensure a sustainable and resilient SNS include improving some access gaps, reducing overuse of low-value care and increasing technical efficiency.

The sustainability of the health workforce remains a challenge for primary care providers

The number of practising medical doctors in Spain is significantly above the EU average and follows the same growing trend as in many other EU countries. However, continued challenges in Spain include a shortage of physicians in some specialties and problems in covering vacancies in some rural areas of the country, in particular, the lack of primary care physicians. Projections for the medical workforce indicate that future needs may not be covered. A plan led by the Ministry of Health aims to increase the number of medical graduates as well as the number of medical interns, and to set up incentives to cover hard-to-fill positions.

Overall, the SNS performs well compared to the EU, but some gaps in access and technical efficiency remain

Spain has the highest life expectancy among EU countries, while rates for avoidable hospitalizations and avoidable mortality (from both preventable and treatable causes) are among the lowest. Moreover, only a small share of the population reports unmet needs for medical care, with minimal differences across income quintiles. However, there is room for improvement in addressing unmet needs for dental and optical care as well as for mental health care, increasing coverage in the colorectal screening programme, and tackling the uneven use of effective treatments and the overuse of non-appropriate or ineffective procedures.