Spain: Health System History - World Health Systems Facts

“The process of health care decentralization to ACs [Autonomous Communities] was completed in 2001, and three laws were enacted in 2003 looking for better institutional integration, coordination and cohesion of the SNS (Law 16/2013), updating and homogenizing legislation for statutory personnel (Law 55/2003), and regulating the different types, roles, training and careers of health professions and specializations (Law 44/2003) (see García-Armesto et al., 2010 for more information).

“From 2004 to 2010, the SNS [National Health System] decentralization process deepened, in the context of the economic expansion cycle and the implementation of the ACs’ Funding Regulation Framework issued in laws 21/2001 and 22/2009. Both laws allowed ACs to spend more funds on welfare services and increase revenues, partially ceding regulation capacity on taxation and devolving, to a certain extent, a number of indirect taxes. On the other hand, the reforms in the statutes of autonomy came to shield the competencies of ACs, strengthening their regulatory capacity in the organization and management of public health care (see Section 1.3, Political control). As a consequence, ACs were able to expand their care network, the supply of services and the workforce (which improved the global payroll), diminishing the coordination capacity of the central planning authorities.

“Late in the 2000s, a wide-ranging debate took place on the role of public action with regard to health determinants. The debate turned into the General Law 33/2011 on Public Health that sets up the principles and actions to be taken to include “Health in All Policies” in the institutional action on health. The General Law also sought to update and upgrade the coordination mechanisms among the 17 health authorities in the country and INGESA, fairly developed in terms of epidemics surveillance and monitoring, but clearly dysfunctional in terms of a common strategy for noncommunicable disease prevention or the development of health promotion and disease prevention interventions. Hence, the new regulation has enhanced the coordination mechanisms in terms of epidemic surveillance and control, and through the Order SSI/2065/2014, has enacted a common package of public health benefits for the whole country (for example, a single vaccination calendar or a common offer of population-based screening programmes) (see Section 5.1, Public health).”

Source: Bernal-Delgado E, García-Armesto S, Oliva J, Sánchez Martínez FI, Repullo JR, PeñaLongobardo LM, Ridao-López M, Hernández-Quevedo C. Spain: Health system review. Health Systems in Transition, 2018;20(2):1–179.

“Since 2011, the regulatory framework was reformed as a consequence of the economic and fiscal crisis, implying the implementation of strong fiscal and consolidation policies; as a result, there have been changes affecting the overall welfare system (for example, decrease of public resources or reduction of public workforce and salaries) and health system-specific measures addressed to reduce the breadth, scope and depth of the system, as well as its central control mechanisms (see Sections 3.3.1, Coverage and 6.1, Analysis of recent reforms).

“After December 2012, with a new government in office and an absolute majority in the parliament, the pace of regulatory changes and austerity measures sped up through the use of “Royal Decree-Laws” – executive decrees that only require ratification in the parliament (a review of legal changes can be found in Repullo (2014)). Main reforms affecting the health system were implemented after the publication of RDL 16/2012, later developed by RD 1192/2012, specifying the condition of SNS beneficiary, and RD 576/2013, establishing the procedure and tariffs for non-entitled individuals who wanted to purchase SNS public coverage (see Sections 3.3.1, Coverage and 6.1, Analysis of recent reforms).”

“The decentralization of health and health care services was completed in 2002 (see Section 2.2, Decentralization and centralization). Over the last decade, the decentralization process consolidated and ACs enjoyed greater capacity for regulation, planning and, above all, financial autonomy. As an unintended consequence, decentralization resulted in an uneven and disproportionate growth of health expenditure that became unsustainable once tax revenues plummeted during the economic crisis (see Section 3.1, Health expenditure). As a consequence of this imbalance, the Government adopted the Stability Programme for the Kingdom of Spain (Ministry of Finance, 2010b), whose major objective in the health sector was the reduction of the public share of health expenditure – from 6.5% of GDP in 2010 to 5.1% in 2015 (Ministry of Finance, 2010b), and the Parliament of Spain approved the Organic Law 2/2012 on Budgetary Stability and Financial Sustainability and the RDL 16/2012 on measures to assure health system sustainability (see Section 3.3, Overview of the statutory financing system). Both legal provisions translated into a recentralization of ACs’ decisions on expenditure – entitling the Ministry of Finance to de facto take over financial control (and consequently the purchasing and provision decisions) – and on decisions on the complementary package of benefits (see below).”

Spain: Health System History - National Policies - World Health Systems Facts

World Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems and policies in the US and sixteen other nations.

Page last updated March 6, 2025 by Doug McVay, Editor.