Quick Facts:

• Population (2009): 40,525,002
• GDP per capita (2008): $34,600
• Life Expectancy (years): M 78, F 84
• Physicians per 10,000 people (2000-2009): 38
• Infant mortality: 4.2 deaths/1,000
• Government health expenditures as percent of total government expenditures (2007): 15.6%
• 99.5% coverage rate through a decentralized National Health System: covers primary care, out and inpatient, surgery, emergency care, long term disease management, some drugs.
• Mental health,  dental and long-term care coverage (though elderly usually cared for by children) require additional supplemental insurance or are paid out-of-pocket (12%)
• National Health System financed by income taxation as well as consumption taxes, funds allocated to 17 communities based on population; Access varies widely by region

Sources: CIA World Fact Book  and WHO World Health Statistics 2010; more statistics can be found at http://www.globalhealthfacts.org

Background Brief

The Spanish government completed its transition to democracy in 1978 by enacting the Spanish Constitution. Health protection, social welfare, and housing are among some of the social rights that the constitution recognized and it therefore laid the foundation for the national health insurance system in Spain today.

The structure of Spain’s health system has evolved since the 80s. After the passage of the constitution, about 82% of Spanish citizens possessed health coverage through a national social security system financed through payroll contributions. Throughout the 1990s, the social security system incrementally transitioned from a social security system financed by payroll contributions into a National Health System financed by income taxation as well as consumption taxes. [1]

Organizational changes accompanied these structural changes, as responsibility for administering health care shifted from the central to regional governments. Today, the health care system is operated by the 17 autonomous, regional governments while the central government outlines the minimum benefits that must be offered and allocates funds to each regional government based on population size. [2]

For the most part, the transition has been successful, yielding a greater than 99.5% coverage rate in 2006. A 2000 World Health Organization study ranked the Spanish health system 7th best in the world. [3] According to the Organization for Economic Cooperation and Development (OECD), Spain’s life expectancy at birth is 80.5 years and its infant mortality rate is 3.5 deaths/1,000 compared to OECD averages of 78.3 and 5.7 respectively. Nonetheless issues remain, namely long waiting times and inaccessible care in some regions as well as a relatively high rate of HIV infection (3.32/100,000 people versus the OECD average of 1.42). [4]

Access
In Spain, the availability of health care varies widely because of the decentralized nature of the national health system. For example, there are 4.8 hospital beds/1,000 people in the region of Catalonia compared to just 2.8 in Valencia. [5] In fact, Spain has averages 3.4 beds/1,000 people throughout the country, lagging the European average of 6.3. The supply of nurses and doctors, however, compares favorably with 3.8 physicians and 7.4 nurses/ 1,000 people compared to European averages of just 3.3 and 6.8. [6] Nonetheless, the regional inequalities in the Spanish health system provide an area for further reform.

Like many other European countries Spanish citizens must receive a referral from a gatekeeper physician in order to receive specialized care. On average, patients wait 65 days to see a specialist although waiting times vary by region (between 23 and 140 days depending on region and type of specialist). [7] These waiting times are slightly longer than those experienced in the UK under the NHS where patients wait on average 60 days to see a specialist. [8]

National health insurance in Spain does not cover dental care. As a result, Spaniards must either pay out-of-pocket or enroll in supplemental insurance policies to see a dentist. In addition, long-term, convalescent care is underdeveloped in Spain, as children tend to care for their parents into old age. [9]

Financing
The Spanish National Health System is financed through a general tax collected by the central government and a consumption tax collected regionally. [10] The central government is responsible for allocating funds to the 17 autonomous communities based on population, and as a result, health care spending varies regionally. [11] In order to control spending, the government enforces global budgeting—an annual cap on health care expenditure—and sets prices for medical procedures covered by the public benefits plan and pharmaceutical goods.

In 2007, total expenditure on health care was 8.5% of GDP or $2,671 per capita up from $1,536 in 2000. This is slightly below the European regional average of spending 8.8% of GDP on health care. [12]

Nearly 72% of spending, $1,917 per capita,capita was financed by the government while the remaining 28% was privately funded. Approximately 16% of total Spanish government spending is devoted to health care. [13] The government expenditure comes from three separate sources—regional government, central government, and social security.

Private health expenditure in Spain also comes from three sources—out-of-pocket payments to the public system (for uncovered care), out-of-pocket payments to the private system, and voluntary health insurance. [14] The proportion of Spanish health care financed by out-of-pocket payments is among the highest in the developed world at 24% (more than every European country except Greece and Switzerland) as both private and public services rely to some extent on these payments. [15] While there is no cost sharing for access to primary care or specialist care services in the public sector, cost sharing for pharmaceuticals and medical aids has been growing since the 90s. [16]

Service Delivery
The Spanish national health system covers primary care, out and inpatient care, surgery, emergency care, acute care, long-term disease management, and some prescription drugs. Mental health, long-term care for the elderly, and dental coverage are not covered and must be paid for either out-of-pocket or with supplemental insurance policies.

Each autonomous region in Spain is broken up into several health areas consisting of 200-250,000 people. The health areas are further divided into health zones of 5-25,000 people generally within a maximum of 35 miles away from the nearest health center. All residents must receive care in their specific zone and are restricted from leaving the zone to see other doctors. [17] About 12% of Spanish residents seek private insurance which provides supplemental benefits like dental care and greater patient choice. In addition, all medical services employees are salaried, civil servants with the exception of those working in private practices who are paid on a fee-for-service basis. [18]

Resources

Anderson, G. F. and B. K. Frogner. (2008). Health Spending in OECD Countries: Obtaining Value Per Dollar. Health Affairs, 27.6: 1718-1727.
This article compares health expenditures among all the OECD countries.

Armesto, S.G. et al. (March 2007). Health Care Quality Indicators Project. Organisation for Economic Co-operation and Development.
This report presents health care quality indicators and patient safety information for several industrialized nations throughout the world.

Duran, A., J.L. Lara, and M. v. Waveren. (2006). Spain: Health System Review, Health Systems in Transition. Organisation for Economic Co-operation and Development. 8.4: 1-208.
This report provides a comprehensive review of many facets of the Spanish health care system including the structure, financing, regulation, and human resources. It also provides an historical account of its development.

Lopez-Casasnovas, G., J. Costa-i-Font, and I. Planas. (September 2005). Diversity and Regional Inequalities in the Spanish System of Health Care Services. Health Economics, 14(supplement 1): 5221-35.
This paper outlines the regional disparities and disparities among ethnic groups in the Spanish health care system.

NHS Waiting Times Cut. National Health Service. March 25, 2009.
This brief from the NHS website discusses the improvement in waiting times between 2007 and 2009 for the NHS.

Organisation for Economic Co-operation and Development. (2006). OECD Health Data 2006: How Does Spain Compare.
This paper provides an overview of health care expenditure data in Spain in relation to other countries in the OECD.

Seoane-Vazquez, E. et al. (November 2009). Spain-Pharmaceutical. International Society for Pharmacoeconomics and Outcomes Research.
This website offers an overview of the Spanish pharmaceutical system including the decision-making, pricing, and reimbursement processes.

Socolovski, J. (August 2009). What Makes Spain’s Health Care System The Best? National Public Radio.
A radio broadcast with a resident of Spain describing the advantages and disadvantages of the Spanish health care system.

Tanner, M. (March 2008). The Grass is Not Always Greener: A Look at National Health Care Systems around the World. The CATO Institute, Policy Analysis, 613: 1-48.
This paper provides a comparative analysis and critique of several national health care systems around the world from the perspective of a market-based proponent.

Toledano, J.R. and M.L.G. Calatayud. (September 2004). SHA-Based Health Accounts in 13 OECD Countries: Country Studies-Spain. Organisation for Economic Co-operation and Development.
This OECD health technical paper provides statistical analysis and empirical data on health expenditure and health accounts in Spain during the year 2001.

“Waiting to Be Seen: How the Health Service Varies across Spain.” Expatica. June, 26 2007.
This article discusses the waiting times for specialists in various regions throughout Spain.

Waters, H. R. et al. (2008). Health Insurance Coverage in Central and Eastern Europe: Trends and Challenges. Health Affairs, 27.2: 478-486.
This paper explores the different systems of health insurance and how they compare in terms of level of expenditure throughout Europe.

World Health Organization. (2008). Country Profiles: Spain.
This WHO website provides an overview, relevant statistics, and various reports on the Spanish health care system.

World Health Organization. World Health Report 2000.
This report provides quality of health indicators and global health rankings for the various health systems throughout the world.

World Health Organization. World Health Statistics 2010.
This report provides extensive data on comparative health statistics for all 193 countries in the World Health Organization.