Letters Assault on universalism

Beginning of the end for Spain’s national health system

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e3213 (Published 08 May 2012) Cite this as: BMJ 2012;344:e3213
  1. Sergio Minué-Lorenzo, senior lecturer1,
  2. José Francisco García Gutiérrez, senior lecturer1,
  3. Juan José Mercader-Casas, senior lecturer1
  1. 1Andalusian School of Public Health, Campus Universitario de Cartuja, 18080 Granada, Spain
  1. sergio.minue.easp{at}juntadeandalucia.es

Strategies to destroy the welfare state are inspired by the American social model, in which poverty is a consequence of idleness and never misfortune.1 Such strategies have reached Spain.2 Last month, under the pretext of trying to save money on healthcare, the Spanish conservative government approved a royal decree law (a legislative instrument for use only in emergencies) that radically undermines the foundations of the national health system.3

Under the General Health Law 1986, the Spanish health system changed from being funded through contributions from affiliated members to social security bodies (the Bismarckian model) to a universal system financed through taxes and free at the point of delivery. This law recognised the right to health protection and healthcare of all Spanish citizens, as well as foreigners with established residence in the country. The new royal decree law, however, substantially modifies the right of people to receive healthcare in Spain; a person is no longer called a citizen but “the insured,” which is clearly defined.

New modes of services portfolios—basic, supplementary, and ancillary—have also been established, which in combination with the concept of insurance facilitates future health service provision by different types of providers, public and private. Ultimately, the law means a change from a tax funded to an insurance based health service.

The Spanish government justifies the reform as necessary to improve health outcomes and reduce the cost of the health service. This kind of argument is supported by Oliver Letwin, now minister of state in the British government, in his book.4 Others call it privatising public assets against the wishes of the electorate.5

As in the United Kingdom, the beginning of the end of the national health service in Spain may be nigh. As Tolstoy said: “There are no conditions of life to which a man cannot get accustomed, especially if he sees them accepted by everyone around him.”


Cite this as: BMJ 2012;344:e3213


  • Competing interests: None declared.