Understanding healthcare in Spain: System, benefits and costs

If you are a user of public healthcare system in Spain or would like to become one, then you will certainly be interested to know what health benefits are provided and how you get healthcare in Spain.

How does the Spanish healthcare system function, where does medical treatment take place and how much does medical care cost in Spain? These are other important questions in this context.

Finally, you will learn about your rights as a user of health services in the Spanish health system.

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How does the Spanish health system work?

‘The Spanish Constitution of 1978 establishes the right of all citizens to effective healthcare protection and equal, efficient healthcare assistance of the highest possible quality’.

La Moncloa (Official website of the president of the Government of Spain and the Council of Ministers)

The Spanish Health System, known as the “Sistema Nacional de Salud (SNS)” provides comprehensive healthcare services (‘asistencia sanitaria’) with is based on the principles of equity, accessibility and universal coverage of a predominantly public nature mainly charged to the State Budget (taxes).

The system guarantees equal access to healthcare services for all citizens and legally residing foreigners, who are entitled to healthcare of the Spanish healthcare system.

In addition to the public coverage the population can carry out a private health insurance.

Regarding the right private health insurance for you in Spain, I can recommend ASSSA’s private health insurance for expats ( professional advice in English).

Organisation

The Spanish health system is a decentralised health system with national coordination.

This means that health competences are transferred to the autonomous regions /communities (‘comunidades autónomas’), which act as a management body for all public healthcare in the region.

National planning and regulation remain the responsibility of the Ministry of Health.

The SNS Inter-regional Council, which comprises the national minister and the 17 regional ministers of health, is responsible for coordination between regional governments and the General State Administration.

How much is healthcare in Spain?

The basic healthcare services in Spain are free of charge.

Co-payments may only be required for pharmaceutical services such as medication and special medical treatments (see below).

Routine dental and ophthalmological treatments are not covered by the SNS. Therefore you have to pay for them or take out a private health insurance that covers this kind of care.

The Spanish public healthcare system is partly funded through social security contributions by those working in Spain (employees or self-employed persons). The cost of social security payments depends on how much you earn.

What health benefits are provided in Spain?

The purpose of the health care benefits of the public health system in Spain is to guarantee the basic and common conditions for comprehensive, continuous care at the appropriate level of attention.

The healthcare services are considered to be the preventive, diagnostic, therapeutic, rehabilitative and health promotion and maintenance services aimed at citizens.

The benefits catalogue of the Spanish health system (SNS) consists of 3 types of benefits: Art. 7 Ley 16/2003

1. General basic healthcare benefits (‘cartera común básica’), which are fully covered by public funds:
   • primary care,
   • specialised medical care,
   • emergency care and
   • urgent ambulance service

2. General complementary benefits (‘cartera común suplementaria’), which are subject to cost sharing by users:
   • pharmaceutical and ortho-prosthetic care,
   • dietary products and
   • non-urgent ambulance service

3. General additional benefits (‘servicios accesorios’), which include all activities, services or techniques of a non-benefit nature that are not considered essential and/or supportive for the improvement of a pathology of a chronic nature. They are subject to cost sharing and/or reimbursement by the user.

In addition to the general state benefits, the complementary health benefits of the autonomous communities are also provided.

In summary, the national health system comprises a range of health services provided by the state administration and the autonomous communities and integrates all health functions and services that are the responsibility of the public sector in order to properly fulfil the right to health protection.

What are the basic health benefits in Spain (without cost sharing)?

a) Primary healthcare (‘atención primaria’):

It is the basic and initial level of health care in Spain, which guarantees the globality and continuity of care throughout the patient’s life. Art. 12 Ley 16/2003

This service includes activities that serve to prevent, promote, maintain and restore health:

• Medical care on request, planned or urgent, both in the consulting room and at the patient’s home.
• The indication or prescription and carrying out of diagnosis and therapies
• Activities relating to prevention, health promotion, family and community care.
• Information and surveillance activities in health protection
• Basic rehabilitation
• Palliative care for terminally ill patients
• Specific care related to women (in particular the detection and treatment of gender-based violence); infancy; adolescence; adults; elderly care; at-risk groups and the chronically ill
• Mental healthcare in coordination with specialist care services
• Oral and dental healthcare

What is part of oral medical treatment?

Dental treatment is not usually covered by the public healthcare system. You will therefore generally have to see a private dentist.

But there are exceptions. Oral care in primary public healthcare involves the following:

• Information, health education and, if necessary, training in hygiene and oral health
• Treatment of acute dental processes (such as infections, inflammations, wounds and injuries to the oral mucosa, tooth extraction, minor oral cavity surgery)
• Preventive examination of the oral cavity in pregnant women
• Preventive and support measures for children in accordance with the programmes defined by the relevant health authorities
• Specialised dental assistance is provided for people with disabilities

The following treatments are excluded from basic oral care:

• Maintenance treatments
• Repair treatment of milk teeth
• Orthodontic treatments
• Extraction of healthy parts
• Treatments for aesthetic purposes only
• Dental implants are only funded for patients with cancer that affects the oral cavity and involves the loss of teeth, and for patients with congenital malformations that occur with edentulism.

How is primary healthcare provided in Spain?

Primary medical care treatment is carried out by a general practitioner (‘médico de familia’), a paediatrician (‘pediatra’) for younger people and a nurse, both in the health centres or doctors‘ surgeries (’centros de salud y consultorios”) and at home.

The doctor and the nurse are initially assigned by the competent health centre. However, it is possible to change doctors later (see below).

To access primary health benefits, you will need the Spanish health card ( ‘Tarjeta sanitaria’) and an appointment (‘cita previa’) with the assigned doctor (family doctor/GP).

You can find out more about access to Spanish public healthcare in my specialised article How to access Spanish healthcare as a pensioner correctly?

b) Specialist medical care (‘atención especializada’)

This is second level of health care in Spain where you find the system’s most complex and costly diagnostic and/or therapeutic resources.

Your family doctor/GP will refer you to a specialist (‘médico especialista’) if he/she considers it necessary.

Direct access to a specialist is not possible.

With the exception of emergencies, patients therefore have no direct access to hospitals or specialised medical treatment.

Specialist healthcare guarantees the continuity of holistic care for patients who have utilised the possibilities of primary healthcare.

This service is generally provided in specialist centres (‘centros de especialidades’) and hospitals and includes: Art. 13 Ley 16/2003

• Specialist care in consultation hours
• Specialist treatment in day clinics, medical and surgical hospitals
• Hospital treatment on the basis of a referral
• Support for primary care in the event of early hospital discharge and, if necessary, hospital treatment at home
• The indication or prescription and carrying out of diagnosis and therapies
• Palliative care for terminally ill patients
• Mental healthcare
• Rehabilitation for patients with recoverable functional deficits

c) Emergency care (‘atención de urgencia’)

Emergency service is provided to patients in cases in which their clinical situation requires immediate health care. It is carried out both in health centres and outside them (including at the patient’s home) 24 hours a day, by means of doctor and nursing care. Art. 15 Ley 16/2003

The patient’s access to emergency care in hospital is by referral from a primary care doctor or a specialist or, if necessary, for emergency or life-threatening reasons that require medical care from the hospital.

Emergency care is coordinated by calling 112 or 061, where you will be attended to in various languages.

It comprises:

• Telephone assistance from the coordination centres for emergencies: Information and health counselling
• Initial and immediate assessment of health risks
• Carrying out the precise diagnosis and medical-surgical therapies necessary to adequately treat the emergency situation
• Monitoring, observation and reassessment of the patient if their situation requires it.
• Health, land, air or sea transport to the required health centre that can best care for the emergency situation.
• Information and counselling of the patient or, if applicable, the accompanying persons about the treatment provided and the measures to be taken
• As soon as the emergency situation is resolved, patients are discharged or, if necessary, hospitalised.
• Notifying the competent authorities, particularly in the event of suspected gender-based violence or abuse of minors, elderly persons and persons with disabilities.

d) Provision of urgent ambulance service (‘transporte sanitario’)

Ambulance services must necessarily be accessible to persons with disabilities. They are used to transport patients exclusively for clinical reasons, whose situation prevents them from using ordinary means of transport. Art. 19 Ley 16/2003

This service is provided when

• the medical transport is urgent : In this case, the service is fully covered by public funds .
• the transport is not urgent: in this case it is subject to an optional prescription for clinical reasons and a co-payment that is defined for pharmaceutical services/medicines (see below).

What are the supplementary benefits (with cost sharing)?

a) Pharmaceutical service (‘prestación farmacéutica’)

This service includes medicines and health products as well as measures aimed at providing patients with the right doses for the appropriate period of time according to their clinical and individual needs. Furthermore, this should be done at the lowest possible cost to patients and the community. Art. 16 Ley 16/2003 and Ley 29/2006

The following products, among others, are excluded:

• Homeopathic medicines
• Cosmetic and dietary products, mineral water, elixirs, dental care and similar products
• Medicines that qualify as advertising

Outpatient medicines can be obtained in pharmacies (‘farmacia’) on the basis of a doctor’s prescription using the ‘tarjeta sanitaria’.

Cost sharing see below.

b) Ortho-prosthetic benefits (‘prestación ortoprotésica’)

This service consists of the use of medical devices, implantable or not, whose purpose is to replace all or part of a body structure, or to modify, correct or facilitate its function. Art. 17 Ley 16/2003

The ortho-prosthesis service includes surgical implants, external prostheses, wheelchairs and orthoses.

The cost-sharing scheme is the same as for medicines (see below).

c) Provision of dietary products (‘productos dietéticos’)

This service comprises dietary treatments (complex dietary therapy) for people with certain congenital metabolic disorders and enteral home nutrition for patients whose nutritional needs cannot be covered, due to their clinical situation, with ordinary food. Art. 18 Ley 16/2003

d) Non-urgent ambulance service

How much do medicines cost in Spain?

The amount of cost sharing for outpatient pharmaceutical services such as medicines depends mainly on the level of income, which can be updated annually, and on whether you are an active worker or a pensioner.

The percentages of cost sharing for medicines prescribed by the medical staff of the Spanish Health System are generally as follows:

a) Insured persons (who are not pensioners) and their co-insured persons:

• 60% of the price of the medicine (PVP) for an annual income of €100,000 or more
• 50% for an annual income of between € 18,000 and € 100,000
• 40% for persons with an annual income of less than € 18,000

b) Pensioners of the Social insurance and their co-insured persons:

• 10% of the price of medication for an annual pension of less than €100,000
• 60% for an annual pension of over €100,000

With regard to the general percentages, there is a maximum participation limit.

c) The following persons are exempt from cost sharing:

• Persons with toxic syndrome and a disability mentioned in special regulations
• Recipients of social integration income
• Recipients of a non-contributory pension
• Unemployed persons who have lost their entitlement to unemployment benefit while their situation persists.
• Treatment for accidents at work and occupational diseases.

ASSSA insurance: The best private health insurance for expats in Spain.

What rights do I have in the Spanish healthcare system?

People who receive public healthcare benefits in Spain have the following rights in particular:

But it needs to say that the free choice is practically limited.

It is possible to freely choose the general practitioner (GP) and the paediatrician within the same health area (‘Área de Salud’) according to your place of residence. Provided that the chosen doctor is not occupied by the assigned number of patients. In Andalusia, there is also the condition that at least three months must have passed since the last choice.

You can also choose a specialist doctor both for care in the reference hospital in your health area and in the specialist centres. Whereby the number of people assigned by the public health service must be taken into account for each specialist.

This choice is made together with your general practitioner, who will provide you with the information you need to make your decision.

The choice of specialist must be maintained throughout the pathological process in question (for long-term processes for a period of at least twelve months). It is not possible to choose several doctors at the same time for the same process.

If you go or travel to another autonomous community (‘comunidad autonoma’), you are entitled to medical care from the catalogue of benefits of the Spanish health system under the same conditions as citizens resident in that autonomous community.

• Information on the steps of the necessary procedures to ensure the continuity of health care.

• Issue of admission, discharge and other reports or clinical documents for the assessment of disabilities or other purposes.
• Medical documentation or certificates of birth, death and other events for the registry office.

Are you satisfied with the health services in Spain?

What experiences have you had with healthcare in Spain in this regard?

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