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Decentralization is the major component of Spain's national health care system

The system has been managed by 17 autonomous regions for about a decade. Ninety-nine percent of the population is covered, but costs are high.

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The Spanish public health system, the Sistema Nacional de Salud, guarantees the right to health care for all Spaniards. The system, decentralized in 1991, is administered by 17 autonomous regional authorities, covering about 99.8% of the population — about 40 million people.

National-level health authorities remain in place to coordinate health policy and international affairs and to regulate pharmaceutical products. All other health programs are organized by the regional authorities, except for public-health and sanitation functions, which are controlled at the municipal level.

According to the Spanish Institute for the Study of Social Advancement, 75% of the costs of the Spanish health care system are covered by public funds, and of the remaining quarter, 85% are direct payments made by individuals. Spanish health care consumes about 7.6% of the nation’s GDP. Per capita, the Spanish government spends about $1,300 annually on health care for its 40 million citizens. To control spending, authorities are trying to limit access to some particularly costly procedures and to separate the roles of insurance, administration and provision of the services through privatization. Several programs designed to abolish dense bureaucracy and paperwork, unwelcome hallmarks of the Spanish system, are also under way.

When it comes to the provision of health care services, the 17 decentralized, autonomous regional divisions, which distribute health care services in a three-tiered system of primary care centers, secondary care centers and major hospitals, continue to purchase many of their hospital services from both private and charitable providers, according to the institute.

Spanish law requires all physicians to work in a public health center or hospital for 37.5 hours per week. Most physicians, after fulfilling their obligation to the public sector, work an additional 4 to 6 hours per day in a private practice.

According to the institute, there are about 40 insurance companies operating in Spain serving about 5.5 million people — or about 14.2% of the population. More frequently, employers are offering private health coverage as part of workers’ compensation. Private insurance costs about $1,000 annually but guarantees timely care in a private setting. Private insurance providers frequently maintain small hospitals and clinics in major cities so that their patients can avoid crowded public facilities. Because the private insurance companies operate with fewer funds and can afford less equipment than the government, major surgery and critical care still occur in public centers.