Will austerity cuts dismantle the Spanish healthcare system?

BMJ 2013; 346 doi: (Published 13 June 2013) Cite this as: BMJ 2013;346:f2363
  1. Helena Legido-Quigley, lecturer1,
  2. Laura Otero, associate lecturer2,
  3. Daniel la Parra, senior lecturer3,
  4. Carlos Alvarez-Dardet, professor of public health4,
  5. Jose M Martin-Moreno, professor of preventive medicine and public health5,
  6. Martin McKee, professor of European public health1
  1. 1London School of Hygiene and Tropical Medicine, UK
  2. 2Faculty of Nursing, University of Lleida, Spain
  3. 3Department of Sociology II, University of Alicante, Spain
  4. 4CIBER en Epidemiología y Salud Pública (CIBERESP), University of Alicante, Spain
  5. 5Department of Preventive Medicine and Public Health and Clinical University Hospital, University of Valencia, Spain
  1. Correspondence to: Helena.Legido-Quigley{at}
  • Accepted 15 March 2013

In the face of austerity, a series of disconnected “reforms” could, without corrective measures, lead to the effective dismantling of large parts of the Spanish healthcare system, with potentially detrimental effects on health. Helena Legido-Quigley and colleagues explain

The financial crisis has hit Spain hard. Initially, given its low government debt, Spain seemed safe, but it was forced to bail out its banks when the housing boom they had been fuelling finally collapsed.1 In the first quarter of 2013, 27% of the labour force were unemployed,2 including over 57% of the under 25s. Poverty has increased. Twenty one per cent of the Spanish population lived below the poverty line in 2012, on less than €7354 (£5980; $9599) annually.3

In June 2012 the Spanish government negotiated a €100bn intervention with the European Stability Mechanism (ESM) to support the banks. In 2012, the general government deficit reached 8.1% of GDP,4 against a target of 5.3%, and its debt rose from 26.7% of GDP in 2007 to 93.8% in 2012.5

The system

Public expenditure on healthcare is low. Although, in 2010, Spain spent 9.6% of GDP on healthcare, 26% of this was from private sources (6% private insurance and the remaining 20% paid by individuals) and 74% was public, with the latter equivalent to 7.0% of GDP, compared to an average of 7.6% in the European Union.6 Yet the Spanish health system is viewed positively by the public. In a 2011 national survey 73.1% of 7800 individuals said that the Spanish system was working fairly well or well.7 Professional dissatisfaction (attributed to low salaries), procurement problems, and limited access to some specialties were issues before the crisis. However, the Spanish system performed better than neighbouring countries.8

The national health ministry is responsible for the equitable functioning of …

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