Analysis Looking to Europe

Spain: a decentralised health system in constant flux

BMJ 2009; 338 doi: (Published 30 March 2009) Cite this as: BMJ 2009;338:b1170
  1. Jose M Martin-Moreno, professor of public health and quality coordinator1,
  2. Paloma Alonso, senior consultant2,
  3. Ana Claveria, quality manager3,
  4. Lydia Gorgojo, chief physician4,
  5. Salvador Peiró, head of the health services research unit5
  1. 1Medical School and Clinical Hospital. University of Valencia, Avenue Blasco Ibañez, 15, 46010-Valencia, Spain
  2. 2Globesalud, Proyectos y Acciones de Salud, Madrid, Spain
  3. 3Servizo de Calidade e Programas, Servizo Galego de Saude, Santiago de Compostela, Spain
  4. 4International Travel Vaccination Centre, Sanidad Exterior de Valencia, Valencia, Spain
  5. 5Centro Superior de Investigaciones en Salud Pública and Escuela Valenciana de Estudios de la Salud, Valencia, Spain
  1. Correspondence to: J M Martin-Moreno jose.maria.martin{at}
  • Accepted 30 November 2008

The Spanish healthcare system is one of Europe’s most efficient, but urgent reform is needed if it is to cope with changing demands and rising costs, argue Jose M Martin-Moreno and colleagues

The Spanish health system offers almost universal coverage, a wide variety of services, and a high quality network of hospitals and primary care centres. Although it is a national system, financed with general tax revenue, the devolution of health services to the country’s 17 autonomous communities has led to a variety of management models.

Spain, like most countries in the European Union, has seen big increases in life expectancy over recent decades thanks to improved living conditions, public health interventions, and progress in medical care.1 2 Spanish citizens born in 2005 can expect to live to 80.4 years old, slightly more than the average in the 15 countries that were members of the EU before 2004 (79.7 years). Maternal and infant mortality as well as other main health indicators and trends are also better than the European average (table).3 Virtually all citizens consider the social support mechanisms in place positively (96.6%) and believe that they have good family support (93.4%).4 The success has been achieved with comparatively low expenditure; despite the trend of increasing costs, a performance analysis shows the Spanish health system to be efficient compared with health systems of neighbouring countries.2 3

View this table:

Main health indicators in Spain and EU average for member countries before May 20045

The system is not without its shortcomings, however. The sustainability of universal coverage is being tested as rising demands lead to rising costs (figs 1 and 2). As well as changes in demographics, patients are expecting more from health services and there are problems with professional satisfaction and resource management.

Fig …

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