The Spanish Constitution of 1978 establishes the right of all citizens to effective healthcare protection and equal, efficient healthcare assistance of the highest possible quality.
In implementation of the mandates contained in the Spanish Constitution, the transfer of powers over health and hygiene (public health) and the provision of healthcare under the Social Security system to the regional governments commenced in 1979. At present, all regional governments exercise these powers, with the exception of the Autonomous Cities of Ceuta and Melilla, where the powers for the provision of healthcare are held by the Institute for Healthcare Management (Spanish acronym: INGESA), a body that comes under the umbrella of the Ministry of Health, Social Services and Equality.
Healthcare professionals (Ministry of Health, Social Services and Equality)However, foreign healthcare, international relations and healthcare agreements, the general framework and coordination of healthcare, legislation on pharmaceutical products, and obtaining, issuing and the recognition of post-graduate professional qualifications all remain the exclusive competence of the General State Administration.
On 25 April 1986, the Spanish Parliament passed the General Health Act, which regulates all actions to enforce the exercise of the constitutional right to health protection. To this end, the law creates a National Health System with universal coverage of a predominantly public nature charged to the State Budget, comprising the Health Services of both the General State Administration and the regional governments.
The approval of the General Health Act marked a milestone for the transformation of Spanish healthcare by bringing together all existing public health and welfare resources into a single mechanism, based on the Social Security resources, and integrating health promotion and disease prevention policies and activities with medical and pharmaceutical services.
Following the transfer of healthcare powers to the regional governments, the legal framework was completed in 2003 with the Quality and Cohesion of the National Health System Act, which provides for coordination and cooperation between public health authorities as a way to ensure the right of citizens to health protection, with the common goal of guaranteeing equal access to services, the quality thereof and citizen participation.
The workings of the National Health System were consolidated in 2003 with another two key laws: the Health System Framework Act 55/2003, of 16 December, which updated and adapted the legal status of public health workers to the new model of healthcare in the State of Autonomous Regions, and aw 44/2003, of 21 November, regulating healthcare professions, which improved the integration of health service professionals by facilitating co-responsibility in the achievement of common goals and improving the quality of the healthcare provided.
Law 33/2011, of 4 October, on General Matters pertaining to Public Health was approved in 2011. This legislation contains the general principles pertaining to public health and establishes the legal foundations underpinning the coordination and cooperation activities carried out by public authorities in this area, with equality as the guiding principle for all health-related policies and actions.
In 2012, Royal Decree-Law 16/2012, of 20 April 2012, setting out emergency measures to ensure the sustainability of the National Health System and improve the quality and safety of its services, introduced certain reforms to ensure the viability and to organise the benefits system.
Within the scope of the regulation of medication and healthcare products, in 2015, by means of Royal Decree-Law 1/2015, the recast text of the Law on Guarantees and Rational Use of Medication and Healthcare Products was approved, which harmonises all the provisions that had modified or extended the original text of this law.
The Inter-regional Council of the National Health System is a permanent body for coordination between regional governments and the General State Administration, set up to foster cohesion in the National Health System by effectively upholding the rights of citizens throughout Spain. The Minister for Health, Social Services and Equality and the Ministers for Health of the regional governments and cities under the State of Autonomous Regions all sit on the Council.
The regional governments have approved their respective regulations under the provisions of the General Health Act, which, while maintaining basic legal principles, establish the organisation of the resources and structure of their regional health service. The Health Service of each autonomous region covers all of its public medical centres and services, acting as a management body for all public healthcare in the region. Each health service depends, in turn, on the health department of the regional government (Regional Health Department), which draws up guidelines and regulations on financing, planning and public health in the region.
The National Health System is organised according to the principles on which it was founded. Given its universal nature and solidarity, the system must guarantee equal access to services for all citizens. Moreover, since it is publicly funded, expenditure must follow criteria of efficiency. Hence, the National Health System is organised into two healthcare levels or contexts in which accessibility and technological complexity are to be found in inverse proportions.
The first-level health services - primary care - are easily accessible and capable of fully tackling the most common ailments. The second level - specialist care - is where we find the system's most complex and costly diagnostic and/or therapeutic resources. The efficiency of these resources is very low if they are not channelled in a concentrated manner and citizens obtain access to them by referral from primary care doctors. Primary care services are provided at medical centres staffed by multi-disciplinary teams of family doctors, paediatricians, nurses, administrative staff as well as social workers, midwives, physiotherapists and pharmacists. Given its position in the community, this level of facility is responsible for health promotion and disease prevention.
|PRIMARY HEALTHCARE CENTRES, HOSPITALS, INSTALLED BEDS AND PHARMACIES
||Rate per 100,000 inhabitants
||They collaborate on provisions of the Spanish NHS
Source: Ministry of Health, Social Services and Equality. Subdirectorate-General of Health Information and Innovation. Catalogue of Spanish NHS Primary Healthcare Centres, 2015. National Catalogue of Hospitals, 2015. Alcántara Information System, 2014 (billing from Spanish NHS prescriptions).
Specialist care is provided in hospitals and specialist clinics as an outpatient or inpatient service. Following the conclusion of this type of care, the patient and the relevant clinical information are referred back to the primary care doctor who, in possession of the full set of patient medical records, can obtain a clinical picture and therapeutic overview.
In this structure, healthcare resources are primarily allocated within set demo-geographical boundaries called health areas. These are set by each regional government taking into account several factors, the most important of which is to locate services near their users.
In order to treat complex or rare pathologies, as well as those requiring a high degree of technological and professional specialisation, the Spanish National Health System has so-called Referral Centres, Services and Units (Spanish acronym: CSUR).
The Referral Centres, Services and Units of the Spanish National Health System must cover the entire national territory and treat all patients based on the principle of equality regardless of where they live, as well as ensure treatment is provided by a multidisciplinary team: healthcare services, support for diagnosis confirmation, therapy and monitoring strategy definition, and consultations for the clinical units that usually treat these patients. Steps must be taken to guarantee continuity of care during the various stages of life of the patient (child-adult) and between the various levels of care, evaluating the results and providing training to other professionals.
Any centre or unit that is proposed as a Benchmark Centre, Service or Unit (Spanish acronym: CSUR) must have a healthcare operation authorisation and be presented as a candidate by the regional government where it is located.
The basic services consist of preventive, diagnostic, therapeutic, rehabilitation and health maintenance and promotion activities. The primary-care level covers general medicine and paediatrics, programmes for disease prevention, health promotion, health education and rehabilitation. Primary-care teams carry out these activities based on their "portfolio of services", which is planned according to the healthcare needs of their catchment area (women's health, child health, adult and elderly health, oral health, terminal patient care, and mental healthcare).
Specialist care includes all medical and surgical specialties. There is also a 24-hour care mechanism for Emergency Healthcare and Medical Emergencies. Healthcare is free at the time of use. In order to standardise the provision of services in each autonomous regions, efforts are being made to update and specify the portfolio of services in certain specific areas. For example, these efforts have led to the creation of a common catalogue of surgical implants and the unification of criteria for screening the population of neonatal endocrine metabolic disorders and colon, breast and cervical cancer.
The public system provides supplementary services, as well as pharmaceutical, orthopaedic and prosthetic services, non-urgent healthcare transportation and diet therapy treatments.
The Spanish Agency for Medication and Healthcare Products is the body commissioned with evaluating medication for the purposes of its registration and authorisation. In turn, the Directorate-General of the Basic Portfolio of National Health System and Pharmacy Services is responsible for deciding whether or not they are to be included on the list of pharmaceutical products offered by the National Health System (Spanish acronym: SNS), as well as for setting the price of pharmaceutical products.
The pharmaceutical service of the National Health System covers the vast majority of medicinal products authorised in Spain, along with certain medical devices, all of which are funded by the public healthcare system. A number of products are expressly excluded from this service, namely OTC medicines, homeopathic medicines, products for cosmetic use, dietary supplements, mineral water, toothpaste and mouthwashes and similar products. Non-prescription medicines and those from non-funded therapeutic groups or sub-groups marketed for the treatment of minor symptoms are also excluded. On 31 December 2015, the total number of medications contained on the list of pharmaceutical products provided by the National Health system amounted to 19,177. Of those, 16.268 (84.8%) are standard packaging medicines while 2,909 (15.2%) are clinical packaging medicines. Of all the standard packaging medicines, 13,837 are medicines that can be billed via medical prescriptions from the Spanish NHS at pharmacies while 2,431 are medicines for hospital use or dispensation; in other words, they can only be used in a hospital environment or at authorised treatment centres. At 31 December 2015, the number of healthcare products included in the pharmacy service of the Spanish NHS stood at 4,784.
Users are participants in the spending on pharmaceutical products dispensed at pharmacists through medical prescriptions issued by the National Health Service, whereby they pay a percentage of the price of the products. This percentage is established according to income, whether an active worker or a pensioner, with a reduced contribution for first-choice products for chronic and serious illnesses. As a general rule, the contribution percentage stands at 60% for those with an income of over 100,000 euros, with a maximum limit for pensioners of 61.75 euros per month. For those people on an income of less than 100,000 euros but over 18,000 euros, the contribution percentage for those in employment stands at 50% and for pensioners at 10%, with a maximum limit for pensioners of 18.52 euros per month. For those people on an income of less than 18,000 euros, the contribution percentage for those in employment stands at 40% and for pensioners at 10%, with a maximum limit for pensioners of 8.23 euros per month. These contributions also depend on the type of medication or healthcare product in question. For medicines or healthcare products for which a reduced contribution is assigned by current regulations, the contribution stands at 10% of the RRP up to a maximum of 4.24 euros per item.
Exemption from these contributions is applied to those people affected by a toxic syndrome and persons with disabilities, who are governed under the specific terms defined by the corresponding regulations, to those people in receipt of social integration incomes, to those people in receipt of non-contributory pensions, to the unemployed who have exhausted their eligibility to receive unemployment benefits for as long as their situation persists, and to those people in receipt of treatments stemming from a workplace accident or occupational disease.
The National Health System has a total of 3,039 medical centres. There are local clinics in many small towns to which professionals from the medical centres in the area travel to provide basic services to the population in rural areas with a high elderly population. There are 10,055 local clinics throughout Spain.
|Primary care staff at the NHS
||Rate per 10,000 inhabitants
Source: Ministry of Health, Social Services and Equality. Subdirectorate-General of Health Information and Innovation. Primary Healthcare Information System (Spanish acronym: SIAP), 2014.
In terms of hospitals, the Spanish National Health System has 451 public hospitals with 122,405 beds (79% of all installed beds in Spain). Of those, 21 hospitals correspond to the Mutual Insurance Companies for Accidents in the Workplace and Occupational Diseases that work with the Spanish Social Security system. The network of hospitals for public use is also included (privately-owned hospitals that offer their healthcare services to a population forming part of the Spanish NHS), as well as the 10 hospitals with approval agreements.
As regards the care function of hospital centres, out of the total number of beds installed in Spain - 154,333 - registered through the Statistics on Specialised Care centres, 126,434 correspond to hospitals specialised in acute pathologies (general hospitals and specialised hospitals), of which 82% are public.
Furthermore, there are another 312 hospitals in Spain providing private healthcare services with 31,928 installed beds.
Although the number of beds defines the resources available for the treatment of patients who are admitted, a better reflection of hospital capacity is obtained by also considering the number of day-care hospital places that do not require or justify hospital admission
The Spanish National Health System has over 16,820 day-care hospital places (36,2 day-care hospital places per 100,000 inhabitants). Day-care hospital places are an alternative to hospital admission in cases of out-patient surgery, the treatment of chronic patients, oncology patients, geriatric patients or those with mental illness, who are treated for several hours at the hospital without the need to spend the night in a hospital bed.
According to the National Statistics Institute, more than 700,000 qualified people were registered with a professional association related to the provision of healthcare activities in 2014. In the same year, the number of registered doctors increased by 2.35% to a total of 238,240; the number of registered nurses increased by 3.1% to a total of 274,817. For every 1,000 inhabitants, 4.6 active doctors are registered and 5.2 active nurses. 48.4% of registered doctors are women, as are 84.3% of active nurses.
At 31.12.2015, a total of 34,888 doctors work in public primary care facilities (28,480 family doctors and 6,408 paediatricians), along with 29,441 nurses and 20,357 non-medical staff. The rate of doctors per 10,000 inhabitants at this first level of care is 7,5.
Hospitals and specialised healthcare centres managed by the Spanish National Health System employ 77,604 doctors (16.7 per 10,000 inhabitants) and 135,959 nurses (29,3 per 10,000 inhabitants). By specialty, physicians working in general surgery and surgical specialties, including Obstetrics & Gynaecology and Traumatology, account for 29% of the total, while those in central services make up 13% and the remaining 58% are specialists working in their medical specialties, including critical care. In addition to these figures, there are personnel in specialist training at public hospitals under diverse systems (22.000 doctors and 1.700 nurses).
Creation of the State Register of Healthcare Professionals will enable better planning and coordination of the human resource policies adopted by the Spanish NHS, as well as the public to be provided with relevant information about healthcare professionals, their qualifications and where they work. Such a complex instrument requires significant regulatory work; at present work is being done on the order to regulate the transfer and operation of the data contained in the register by the public authorities.
Every year, more than 239,8 million visits are made to doctors - more than 371 million if we include nursing activities - at National Health System medical centres and clinics. The annual rate of visits to primary care doctors per inhabitant is 5.2 (5.3 for visits to family doctors and 5 to paediatricians) and 2.9 for nursing visits.
|Primary care activity at the NHS centres
||5,2 (239,8 million visits)
|Medicine - Family Medicine
||5,3 (206,8 million visits)
|Medicine - Paedriatics
||5,0 (33,0 million visits)
||2,9 (131,2 million visits)
||5.3 (371,0 million visits)
Source: Ministry of Health, Social Services and Equality. Primary Care Facility Information System 2010-2014.
13,9 million consultations are provided per year as part of scheduled home visits, of which 10,4 million (74,8%) are provided by nursing professionals. The majority of this activity is received by people over the age of 65.
Emergency healthcare services under primary healthcare activity amounts to 26.6 million visits per year, the majority of which (94%) are received at healthcare centres and 6% in the home.
In terms of specialist care, Spanish hospitals perform over 5.2 million patient discharges per year, of which 4 million (76,5%) are financed by the National Health System. Moreover, 94 million visits are made to different specialists each year (83.4% financed by the National Health System), 26.7 million emergency visits are made (77.3% through public funding) and 5 million operations are performed per year (71,3% in National Health System hospitals or funded thereby).
|Specialist care activity in total and in the NHS 2013 - 2014
|Major outpatient surgery (thousands)
Source: Ministry of Health, Social Services and Equality. Specialised care facility information system 2010-2014. (Year 2014 Provisional data).
Spanish hospitals are at the global forefront of organ and tissue transplantation, which is performed at approved facilities. Organ donation requires the consent of the donor.
The number of deceased donors stands at 1,851 (40.2 per million population), which enabled 4,769 transplants.
Hospital network and transplant teams
|Pancreas-kidney transplantation and combinations
Source: Ministry of Health, Social Services and Equality. Spanish National Transplant Organisation (Spanish acronym: ONT), 2014
The technological equipment used at medical centres and hospitals is comparable with that used in the most advanced countries and allows Spanish citizens to benefit from the highest standard of care through high-tech equipment that allows tests such as computerised CT scans and MRIs.
|Organ donation and transplantation, number and rate per million population (p.m.p.)
Source: Ministry of Health, Social Services and Equality. Spanish National Transplant Organisation (Spanish acronym: ONT), 2014
In 2015, the number of pharmacies in Spain that collaborated in the provision of pharmacy services by the SNS amounted to 21,919, which, taking into account the Spanish population, means there is one pharmacy per 2,119 inhabitants. Hence, the ratio per 100,000 inhabitants stands at 47.2 pharmacies.
Health in Spain is a non-contributory benefit financed through taxes. Since 2002, it has been included in the general funding for each autonomous region.
Carlos III Hospital (Ministry of the Presidency)Data for 2014 put public health spending in Spain, including long-term care, at 66.826 million euros, 6.4% of GDP. Private health spending amounted to 28.895 million euros (2.8% of GDP).
Health spending is the biggest budget item after pensions and on average accounts for over a third of spending by regional governments. Breaking down public healthcare spending in 2014, the major expenditure by percentage was hospital and specialised services (61,4%), followed by pharmaceuticals (16,8%) and primary healthcare services (14,6%). In terms of its economic and budget classification, not including expenditure on long-term care, the remuneration of personnel is the item with the biggest weight in public healthcare spending, at 45.0% in 2014. Outsourced activity accounts for 11.7%.
In Spain, healthcare is guaranteed to individuals who are covered by the system. Foreign nationals not authorised or registered as residents in Spain receive emergency medical attention for serious illnesses or accidents (whatever the cause) until discharge. Female foreign nationals also receive pregnancy, delivery and postpartum care is provided that no third party is required to pay. Foreign nationals under the age of 18 receive healthcare under the same conditions as Spanish citizens. The public health system has no set waiting periods or any other requirements to access its services, which are comparable with those of most European countries.
The rights and obligations of citizens in regard to public healthcare is contained in the main legal regulations mentioned above and are designed to guarantee their right to equal access to healthcare of the highest standards of quality and efficiency, and respect the principles of autonomy and freedom. Act 41/2002, of 14 November, passed in 2002, requires the health services to inform citizens of all their rights and obligations, including those under State legislation and those contained in the relevant regional regulations. One of the most far-reaching consequences of this law is that for the first time citizens are granted the right to seek a second opinion on their condition. Other significant developments introduced by this law concern the regulation of 'living wills' and informed consent.
|Satisfaction with the health system. Percentage of opinion on how the health system operates
|It works well
|Total overhaul needed
Source: Ministry of Health, Social Services and Equality and the Sociology Research Centre. Healthcare Barometer 2010-2014.
In the Spanish healthcare system, the citizen is at the centre of all activities, which is why regular surveys are conducted to gauge public satisfaction with the health system. The results of these surveys indicate a high degree of citizen satisfaction with how the public health system is run, although it would also seem to indicate a declining trend.
For example, according to the overall results of the 2014 survey, more than two-thirds of the population consider the National Health System to be well run. The positive results obtained in the health system survey are also reflected in the excellent health indicators of the Spanish population.
According to the National Statistics Institute (Spanish acronym: INE), life expectancy at birth in Spain in 2014 stood at 82.9 years of age (80.1 for men and 85.7 for women). This has increased by 3.2 years over the period 2001-2014.
At the age of 65, life expectancy in Spain stands at 21.1 years; 19.1 for men and 22.9 for women. Between 2001 and 2014, this life expectancy at 65 rose by 2.1 years. These positive increases in life expectancy at birth and at 65 have been seen in both men and women, as well as in all autonomous regions.
When comparing Spain with the average for the countries making up the European Union, Spain has higher figures in terms of both life expectancy at birth and life expectancy at 65. The EU average stands at 80.9 for life expectancy at birth and 19.9 for life expectancy at 65 (UE-28. Eurostat Statistic Database Health at a Glance: Europe 2016-Draft not for circulation).
With 2.8 infant deaths per thousand live births in 2014, Spain is among the top seven EU countries with the lowest infant mortality rate, and is also below the average infant mortality rate for all EU countries, which currently stands at 3.7 deaths per 1,000 live births.
Frontage of Gregorio Marañón Children's Hospital (Gregorio Marañón General University Hospital)Spain's National Health System, as with the health systems of our developed peer countries, faces the challenge of improving the quality of the services it offers to citizens without compromising the sustainability of the current healthcare model. An ageing population is having a major impact on disease patterns and the consumption of health services and, together with the emergence of new diagnostic and treatment technologies and the increased demands of citizens, it is driving spending increases and the introduction of policies geared towards improving the efficiency and effectiveness of healthcare measures.
Improving the health of the population is at the heart of all strategic lines characterising the current health policy, designed by the Ministry of Health, Social Services and Equality and the regional governments. These strategic lines include:
- Driving through policies to prevent disease and protect and promote health.
- Giving fresh impetus to both basic and applied health research.
- Development of the strategy to tackle chronic illness, strengthening the strategic role played by primary healthcare.
- Continuity with the policies and measures to manage the streamlining of the provision of pharmaceutical services contributes to the rational use of medication and healthcare products.
The implementation of new financing criteria for access to latest generation medication.
Prudent use of antibiotics and the fight against antimicrobial resistance.
The introduction of criteria to evaluate diagnostic and therapeutic technologies and procedures, and the development of the guarantees of security, quality and efficiency of healthcare products.
Efficient use of information and communication technologies, both to improve patient care, and to be implemented throughout the system, clinical files and interoperable electronic prescriptions, based on the common system of identification through the healthcare card that exists in the Spanish health system.
Planning of the needs of healthcare professionals over the medium and long term. This planning will be carried out based on the figures contained in the State Register of Health Professionals.
The new model of specialised healthcare training which, through the introduction of criteria of core subjects, will allow the already excellent training of Spanish health professionals to be improved.