Intended for healthcare professionals


New legislation transforms Spain’s health system from universal access to one based on employment

BMJ 2012; 344 doi: (Published 09 May 2012) Cite this as: BMJ 2012;344:e3196
  1. Aser García Rada
  1. 1Madrid

Spain’s public health service is to shift from one that provides universal coverage through general taxation to a system funded through social security contributions, after the conservative People’s Party government of Mariano Rajoy passed new legislation.

Although the new law represents a major change to the General Health Act that established Spain’s national health service in 1986, the legal mechanism chosen by the government was a royal decree, which does not require parliamentary debate.

The so called “royal decree on urgent measures to ensure the sustainability of the national health system and improve the quality and safety of its services” includes decisions previously taken by the Inter-territorial Council on 18 April and on 20 April by the cabinet.1 Among other things, these measures extended drug copayments and limited illegal immigrants’ access to healthcare.

However, the full extent of the changes being imposed on the Spanish health system only became evident when the decree was published on 24 April.

The implications of the legislation have caught observers by surprise and attracted extensive criticism from opposition parties, trade unions, health professional groups, and the Spanish Patients’ Forum (Foro Español de Pacientes).

The law, which takes effect on 1 September, regulates access to healthcare by introducing the term “insured,” which may be used in the future to allow private insurance companies into public healthcare, warned Gaspar Llamazares, a congressman of the United Left party and former president of Congress’s cross party health committee.

The legislation establishes that people aged over 26 years of age who have never worked will have access to public healthcare only if they declare that they have no income. Pensioners’ access is guaranteed if they are legal residents and have previously contributed to the social security system. Unemployed people will be covered if they are collecting unemployment benefits or are listed in government offices as job seekers.

“It is a throwback to the 1980s,” said Llamazares.

Joan Carles March, a professor at the Andalusian School of Public Health, said, “A consensus must be sought for a change of this size. We have moved from [being] citizens to policy holders or beneficiaries.”

Pilar Farjas, undersecretary for health at the Ministry of Health, Social Services, and Equality, denied that the funding model had changed and said that the decree’s changes were limited to “regulation of the recognition of the right to public healthcare.”

The law establishes that immigrants “not registered or authorised as residents”—about 150 000 people—will have access only to emergency, maternity, and paediatric care, a measure that may be contrary to the Spanish Constitution and several regional legislations, says the General Council of Lawyers (Consejo General de la Abogacía). Irregular immigrants have had full healthcare coverage since 2000.

Chaouki Smaali, a 40 year old immigrant who is HIV positive, told the newspaper El País, “I need the pills for HIV, and I won’t be able to pay for them.”

However, even if Smaali had the money, he wouldn’t be able to get his drugs, because they require a prescription to be filled out by a hospital pharmacy, which wouldn’t be allowed under the new rules. Some exceptions to the rules will be allowed, though these haven’t been decided, said a ministry spokesman.

The measure is another blow to people with HIV, after the national plan against AIDS was withdrawn a month ago.1

March criticised Spain’s hypocrisy in allowing immigrants to work in Spain, albeit illegally, while refusing to attend to their healthcare needs. “It is a serious mistake” with public health implications, he said.

The law also establishes that copayment will be extended to prostheses, wheelchairs, certain therapeutic diets, and non-emergency medical transport.

Public funding of minor drugs will also be withdrawn, a measure that had been demanded by Farmaindustria, the national association of drug companies, to avoid further discounts on brand name drugs.2

Farjas justified the decree as a way to deal with the growing public healthcare debt3 and “lack of action” in the past few years. “Spaniards now have healthcare armoured against the economic situation,” she said.

However, several commentators have warned that the economic crisis is being used as an excuse to implement major changes to the health service that had not been included in the Popular Party’s electoral programme in the general election at the end of last year.


Cite this as: BMJ 2012;344:e3196



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