Introduction

This year 2006 marks the twentieth anniversary of the passing of the General Health Act 14/1986, dated 25 April. This law made it possible to move from the former Social Security health system to the current National Health System, which is financed from general tax revenue and offers almost universal coverage. Far-reaching changes have taken place since then, including the transfer of powers to the Autonomous Communities which was completed in 2002, making public health one of the main pillars of the welfare state in Spain today.

This publication offers the general reader a simple description of the main features of the Spanish National Health System today, giving an overview of Spanish public health. It comes together with some facts and figures on the current situation and structure.

First, an explanation is given regarding the distribution of powers amongst the different levels of the Administration and especially between the State and the Autonomous Communities. Some key aspects of the Spanish National Health System - coverage, funding, organisation and services are then described briefly, and data are given on the facilities and human resources within the system and the activities they generate. Figures are also given on public health expenditure and on users’ satisfaction with the system. The last section gives some facts and figures on health in Spain. Finally, the annexes offer information on the Inter-Territorial Board, which is responsible for coordination and cooperation amongst the Autonomous Community Health Departments and the central Administration, and a brief description of the functions and structure of the Ministry of Health and Consumer Affairs.

The aim of this publication is to serve as a general introduction to the public health system in Spain. But it comes together with a leaflet containing tables and graphs that can be used as quick reference material on the main facts of the Spanish National Health System. The statistics have been drawn up and, to a great extent, produced by the Health Information Institute, which forms part of the Quality Agency of the Ministry of Health and Consumer Affairs (www.msc.es).


Health protection in Spain

The right for all citizens to enjoy health protection and care is laid down in article 43 of the Spanish Constitution of 1978.

The main principles governing the exercise of this right are
regulated by the General Health Act 14/1986, as follows:

The National Health System is therefore made up of both the State and Autonomous Community Health Departments and covers all the health functions and services for which the public authorities are legally responsible.

State powers

General organisation and coordination refers to the regulation of conditions and minimum requirements, aiming to achieve equal conditions in the functioning of public health services; the creation of methods for the sharing of information, technical standardisation in specific areas, and joint action by State and Autonomous Community authorities in the exercise of their respective powers.

International health refers to the surveillance and control of possible health risks in connection with the import, export or traffic of goods and international passenger traffic. Spain collaborates with other countries and international organisations through international relations and health agreements:

Regarding Pharmaceutical products, the powers held by the State are as follows:

Irrespective of the powers held by the Autonomous Communities and, where appropriate, in coordination with them, the State Administration also carries out actions in the following areas:

Powers of the Autonomous Communities

The Spanish Constitution of 1978 established a territorial structure that allowed devolution to the Autonomous Communities of powers in the area of health. As a result, through their respective Autonomy Statutes, all the Autonomous Communities have gradually taken on such powers. The devolution of health care powers from the National Health Institute (INSALUD) began in 1981 and was completed in 2002, with the Central State Administration
keeping the responsibility for health management in the Autonomous Cities of Ceuta and Melilla, through the National Institute for Health Management (INGESA).
The Autonomous Communities now hold powers for:

Source: Ministry of Health and Consumer Affairs. General Department for Cohesion in the National Health System and the Senior Inspectorate





Each Autonomous Community has a Regional Health Service, which is the administrative and management body responsible for all the centres, services, and facilities in its own Community, whether these are organised by regional or town councils or other intra-Community Administrations.

The principles governing health coordination on a nationwide level are laid down in the General Health Act 14/1986 of 25 April, which also specifies the tools for collaboration and creates the National Health System’s Inter-Territorial Board as the coordinating body.
Subsequently, Act 16/2003 of 28 May on Cohesion and Quality in the National Health System deals in greater depth with the role of the Inter-Territorial Board as the coordinating body and with general coordination and cooperation within the National Health System.

The devolution of powers to the Autonomous Communities is a means of bringing the management of health care closer to citizens and thus guaranteeing equity, quality and participation. Practical experience of relations between the State and the Autonomous Communities in the area of health protection provides important references for the development of cohesion in the State of Autonomous Communities. All those involved are working to achieve a common identity for the National Health System, based on the constitutional principles of unity, autonomy and solidarity.

The Law on Cohesion and Quality in the National Health System therefore requires coordination and cooperation amongst the public health administrations in order to guarantee the right to health protection and to ensure:

a) Equity, according to the constitutional principle of equality, guaranteeing access to services and the right to health protection in conditions of real equality throughout the Spanish territory and allowing free movement by all citizens.
b) Quality, with the inclusion of safe and effective innovations, and orienting the system towards the anticipation and effective solution of health problems. The benefit of clinical actions should be evaluated, so that only those actions that improve health are taken,
involving all agents in the system.
c) Participation by citizens, regarding both autonomy in their individual decisions and the consideration of their expectations as users of the health system, in order to ,facilitate the exchange of knowledge and experience.


Coverage
The rights to health protection and health care are held by:

Spanish civil servants and their dependants may have recourse to special insurance regimes through the civil, military or judiciary mutual funds (MUFACE, ISFAS and MUGEJU respectively).
The Spanish population as registered on 1 January 2005 numbered 44,108 million, of whom 8.4% were foreigners and with 16.7% being aged over 65.

Access to services is gained on presentation of the Personal Health Card issued by the respective Health Department. This document identifies each citizen as a user for the whole National Health System.


Funding

Health care in Spain is a non-contributory benefit. It is paid for through taxation and is included in the general budget for each Autonomous Community. Two additional funds are the Cohesion Fund managed by the Ministry of Health and Consumer Affairs and the Savings Programme for Temporary Incapacity.

Health care is one of the main instruments of policies to redistribute income amongst Spanish citizens: all citizens pay taxes in line with their financial capacity and receive health services as needed.

Organisation

The Spanish National Health System is organised in line with its basic principles. Since it aims to provide universal support, it has to ensure equal access to services for all citizens and, since it is financed with public funds, expenditure must be based on efficiency criteria.

The System is therefore organised at two care levels in which accessibility and technological complexity are counterpoised.

The first level – Primary Health Care – is characterised by extensive accessibility and sufficient technical resources to resolve the most frequent health problems.

The second level – Specialist Care – has more complex and costly diagnostic and therapeutic resources which have to be concentrated in order to be efficient. Access is gained by referral from Primary Health Care.

Primary Health Care aims to provide basic services within a 15-minute radius from any place of residence. The main facilities are the Primary Care Centres which are staffed by multi-disciplinary teams comprising general 30 Organisation practitioners, paediatricians, nurses and administrative staff and, in some cases, social workers, midwives and physiotherapists.

Since this level is located within the community, it also deals with health promotion and preventive health care. Maximum accessibility and equity means that Primary Health Care also reaches homes when necessary.

Specialist Care is given in Specialist Centres and Hospitals, for both in- and out-patients. Once care is complete, the patient is referred back to the Primary Health Care doctor who uses the full medical history as a basis for subsequent treatment and overall care. This means that continued care is given in equitable conditions, irrespective of the place of residence and individual circumstances, and care will be given in the patient’s home if necessary.

Each Autonomous Community establishes its own Health Areas according to demographic and geographic criteria aiming, above all, to guarantee service proximity for users.

The Health Areas are then sub-divided into Basic Health Zones, which are the territorial framework for Primary Health Care and the Primary Care Centres. Each Area has a general hospital for Specialist Care. In some Health Departments there are intermediate structures between the Health Area and the Basic Health Zone.

Services
The services offered by the Spanish National Health System include preventive care, diagnostic and therapeutic techniques, rehabilitation and health promotion and maintenance.

Primary Care
This is the level involving most of the activities in the field of health promotion, health education and preventive medicine.
Health care is delivered both on demand and in a programmed way and in Primary Care Centres, rural outpatients’centres and patients’ homes.
Medical and nursing care is also provided round-the clock –in patients’ homes, if necessary – for urgent health problems.

Finally, physical rehabilitation and social support services are also offered.
Specific activities are also carried out, most of them focusing on specific groups:

Specialist Care

This includes care, diagnostic and therapeutic activities and rehabilitation. Care activities include those aspects of health promotion, education and prevention which are best carried
out at this level.

Services are provided for both out- and in-patients, sometimes via day hospitals which mainly offer out-patient surgery and diagnostic and therapeutic techniques requiring special monitoring.

Out-patient consultations are offered by the different medical and surgical specialists and diagnostic and therapeutic activities are carried out. In Mental Health and Psychiatric Care, diagnosis and clinical monitoring are carried out, with drug therapy and individual, group or family psychotherapy and hospitalisation as required, with the express exclusion of psychoanalysis and hypnosis.
Hospitalised patients receive medical, surgical, obstetric and paediatric care for severe diseases and recurring chronic processes, with treatments or diagnostic procedures as required.
Emergency care is available round the clock for out-patients.

Other services

Spain is one of the countries that carries out most transplants. In 2004, there were 34.6 organ donors per million inhabitants. (Source: Ministry of Health and Consumer Affairs. National Transplant Organisation)
Liver (1040)
Kidney (2186)
Heart (294)
Pancreas (74)
Intestine (7)
Lungs (143)

Pharmaceutical services

These cover drugs and health products as well as actions aiming to ensure that patients receive drugs as required, at the right dosage, during the right time and at the lowest possible cost for them and for the community.

Unlike other services which are provided free of charge, pharmaceutical, orthopaedic and prosthetic services are cofinanced by users, as follows:

Source: Ministry of Health and Consumer Affairs. Directorate General for Pharmacy and
Health Products

Orthopaedic and prosthetic services

These cover the elements required to improve patients’quality of life and degree of autonomy.

They include health products, whether implants or not, that totally or partially replace a body structure or modify, correct or facilitate its function.
Services are laid down in a specific catalogue.

Health transport

The transport of patients for clinical purposes when their situation does not allow them to use ordinary means of transport, in emergencies or when the patient is physically incapacitated.

Dietary products

The dispensing of dietary treatments to people with certain congenital metabolic disorders, and enteral feeding in patients’ homes when their clinical situation does not allow
them to ingest ordinary food.

Information and Health Documentation Services

The National Health System also offers a number of services that complement health care:

Facilities and Activities

Facilities and resources

The National Health System has 2,702 Primary Care Centres. There are also medical centres in small towns to which the staff of the zone’s Primary Care Centre travel in order to provide basic services to the local population. These are mostly in rural areas, which tend to have a high proportion of elderly patients.

Source: Ministry of Health and Consumer Affairs. Regional Departments of Health of the Autonomous Communities and the National Catalogue of Hospitals
(1) Year 2004


The National Health System also has 293 hospitals, with 103,592 beds. There are also 24 hospital establishments owned by Mutual Funds for Industrial Accidents and Occupational Diseases, as well as 454 private hospitals in which 40% of discharges are for patients whose hospital care was arranged and financed by the NHS.

Spain has 129,389 beds for acute pathologies, of which 71.6% belong to the National Health System.

Approximately 38% of the 16,141 beds available for psychiatric care and of the 12,396 for geriatric and long-term patients belong to the National Health System.


Human Resources
There are more than half a million people in Spain working in the health sector who are qualified and registered with a professional association. The largest group is that of nurses which also contains the highest proportion of women.

A total of 422,471 staff provide their services in the National Health System, 20% in Primary Care and 80% in Specialist Care.

Registered health professionals, 2004

Source: National Statistics Institute INE

Human Resources in National Health System, 2003

Source: Ministry of Health and Consumer Affairs. Estimate drawn up by the HealthInformation Institute


27% of doctors in Specialist Care work in internal medicine and other specialist branches of medicine, 23% in central departments (clinical analysis, microbiology, radiodiagnosis, etc.) and 18 % in surgery and surgical specialisations.

In Primary Care, 82.2% of doctors are specialists in Family and Community Medicine and 17.8% in Paediatrics.


Activities
In Primary Care, over 300 million consultations are given every year, with a rate of 7.4 consultations / inhabitant / year.

Consultations are either requested by users or are programmed by doctors or paediatricians. Primary Care nurses carry out both programmed activities and technical actions in diagnosis and health care.

In Specialist Care, more than 3.8 million hospital discharges a year are financed by the National Health System.

Some 60 million consultations are given by different medical specialists. 18.3 million emergency cases are seen and 2.9 million surgical actions are taken.


Financing and Public Health expenditure
The latest official figures set public health expenditure in Spain at 41,199.7 million euros. This represents 71.4% of total health expenditure in Spain which amounts to 57,698.7 million euros.

Health expenditure in Spain accounts for 7.7% of GDP in 2003

Public health expenditure accounts for 5.5% and private health expenditure 2.2% of GDP.

Hospital and specialist services account for the largest percentage of expenditure, followed by pharmaceutical services and primary health care.

Public health expenditure, 2003
Breakdown by functional items

Transport, prothetics and therapeutic equipment 1.7%
Capital expenditure 3.9%
Pharmacy 22.3%
Hospital and specialist services 52%
Collective health services 2.8%
Public health services 1.3%
Primary health care 16%
Source: Ministry of Health and Consumer Affairs. Public health expenditure.


The reason for the apparently small relative weight of Public Health is partly because of the way in which this activity is defined and classified in accounting systems but also because
public health, prevention and promotion activities are mostly carried out through the Primary Care network.

Regarding budgetary classification, staff remuneration is the largest item in health expenditure.

Contract activities account for 11.8%.

Public health expenditure, 2003
Breakdown by budgetary items

Ordinary transfers 23.5%
Capital expenditure e 3.9%
Contract 11.8%
Fixed capital use 0.4%
Staff remuneration 43.3%
Intermediate consumption 17.1%
Source: Ministry of Health and Consumer Affairs. Public health expenditure

To inform inhabitance and people from abroad about our National Health Care service the following broschure was publishes.
Informative brochure of the Aragonian Health Service to foreign-origin users (download [28 KB] )