The Spanish National Health System (SNS) is one of the most valuable achievements of our democracy. No other has contributed so much to equality among Spaniards, social cohesion, the sense of belonging to a single community, and even to the system’s own legitimacy. But it is crumbling before everyone’s eyes. Therefore we must speak plainly about what many suspect and few dare to say: the SNS seems to be dying. It would not be a sudden death. It would, if anything, die from a progressive deterioration accepted as a lamentable normality. Ernest Lluch, then Health Minister, pushed through the most substantial health reforms. First, the decree that consolidated the MIR system for medical specialty training (RD 127/1984) and the reform of primary care (RD 137/1984). Then, the General Health Law of 1986 (LGS), the legal articulation of a certain idea of society in which health protection (Article 43 of the Spanish Constitution, CE) ceased to depend on work or economic status to become a citizen’s right. I was fortunate to participate in those reforms, among many others convinced that it was possible and necessary to build a universal health system.
The Spain of the eighties already possessed an aid apparatus —not a true “system” or a “network”— that was uncoordinated, heterogeneous, and each element targeted at a different group. It had been built around Social Security (with INSALUD as the managing entity), the Ministries of the Interior and Education, provincial councils, mutual societies, and various public and charitable entities. The LGS introduced a new conceptual logic and, consequently, also an organizational and health framework: health protection as a legally protected value, universal coverage, public financing from taxes, health planning, the functional integration of the different services, primary care as the backbone, and, finally, decentralization.
Forty years have passed and
There were many years in which the system worked, and worked well. The Spanish SNS was regarded as one of the most efficient examples of universal coverage. Spain still today boasts one of the highest life expectancies in the developed world. The indicators of avoidable mortality —which includes both preventable and treatable mortality— and avoidable hospitalizations place Spain in very favorable positions within Europe, being 28% and 10% lower, respectively, than those of the European Union. Total health expenditure in Spain —public and private— sits around 20% below the EU average (about €3,100 per inhabitant versus nearly €3,800 in 2023). As a share of GDP, it has never reached the levels of Germany, France, the United Kingdom, or, of course, the United States. The public health expenditure, which rose in 2024 to around €102 billion, is 6.7% of GDP, almost 40% below Germany’s 10.6% and less than half the United States’ 14.3%.
Thus, the Spanish SNS managed to combine universality, good results, and moderate spending, which has been described as a kind of “health paradox.” Reasons are multiple: strong professional commitment, effective primary care during its first decades, lower management costs, a family structure that cushions demand for institutional care, and a large capacity for hospital care.
But part of that efficiency rested on aspects such as underfunding of the system, overburdening of its professionals and a spending containment that looked like virtue when it was, in part, a postponement of real needs. For a long time, the SNS functioned thanks to a combination of factors —from professionalism to the creativity in organizing itself— that is very difficult to sustain indefinitely.
Today, the SNS, though not suffering a sudden and direct fall, does undergo the most serious crisis in its history. The SNS continues to care for millions daily with extraordinary technical competence and professionalism. Yet clear signs of accumulated fatigue exist: rising waiting lists, deteriorating accessibility in primary care, growing professional conflict, governance difficulties, territorial fragmentation, technological pressures without sufficient financial backing, and, above all, the most novel and important development, growing user disaffection accompanied by a progressive expansion of private insurance as an outlet for those who can afford it.
A System Designed for Another Spain
The SNS was designed for a Spain very different from today. The Spain of 1986 was younger, less long-lived, less technological, less medicalized, with a much lower chronic burden and more limited health expectations. The Spain of 2026 is radically different on all those parameters.
“The Spain of 1986 was younger, less long-lived, less technological, less medicalized”
Life expectancy at age 65 has risen by five years since the early eighties (from 16.52 years in 1980 to 21.87 in 2024), a huge health and social success. But it also completely transforms the nature and intensity of care demand. Medicine now saves lives that would have been lost, prolongs survivals inconceivable decades ago, and converts once-mortal diseases into chronic conditions that concentrate 80% of health spending. That same success generates multimorbidity, dependence, prolonged need for care, increasing pharmacological pressure, and a structural rise in spending that cannot be offset by efficiency alone.
Decentralization constitutes one of the most important, complex, and contested processes in the history of the SNS. Transfers responded to the state’s autonomous structure, to political demands for self-government, and also to a search for closer administrative proximity. On January 1, 2002, transfers to the ten autonomous communities (ACs) that still depended on INSALUD were completed. It was the largest transfer of resources in the history of the Spanish State: €12,000 million and 140,000 public employees, 83 hospitals and 35,000 beds. Seven other ACs —Catalonia, Basque Country, Navarre, Andalusia, Galicia, Canary Islands and the Valencian Community— had already progressively assumed health competencies since 1981. INSALUD disappeared.
The transfers have driven the development of regional institutions, organizational innovation in some ACs, and perhaps better adaptation to local particularities. But decentralization also generated cohesion and governance problems that cannot be ignored. In practice, the SNS operates as an “imperfect federation of regional health services.” Divergences between ACs in per-capita health expenditure, waiting lists, access to certain benefits, staff working conditions, and investment in technology are so large that they should be uncomfortable for any government. Yet the Spanish Government —all the governments there have been— has prioritized caution in its relations with the ACs over guaranteeing citizens’ equity in access to care. Can true health equality be spoken of, even the protection of health as a right for all Spaniards, when funding and functional capacity differ so notably by residence? Is equity possible when one autonomous community spends around €1,650 per inhabitant on health and another more than €2,300?
The pandemic did not create the SNS’s problems, but it made them visible with brutal clarity. Spain abruptly faced hospital saturation, extreme ICU pressure, partial collapse of primary care, devastating and inhumane mortality in care homes, physical and emotional exhaustion of its professionals, and serious coordination difficulties interterritorially. All this harshly revealed the inadequacy of public health, dependence on external supplies for critical inputs, lack of strategic reserves, and weakness of territorial information systems and interoperability.
Spain’s response to the first wave of the pandemic was worse than in other European countries, with mortality above the EU average, only comparable to England, which was higher. Yet, the system’s resilience was notable: vaccination campaigns were carried out with effectiveness that placed Spain among the countries with the highest vaccination coverage in the world.
In that context, in April 2020, a large group of health professionals —care providers, managers, epidemiologists, academics, former ministerial heads and former INSALUD directors— promoted the document For a Re-foundation of the SNS, sent to the Government Presidency, which acknowledged receipt and forwarded it to the Ministry of Health. However, we never received a response. The same document was sent to the corresponding commission of the Congress of Deputies, and it is not an exaggeration to say that it was one of the strongest among those handled by the parliamentarians, but nor there did it receive any response or interest from any political group.
That document, signed by almost 350 experienced professionals from all levels of the system, not obtaining institutional response —neither from the Government nor from Parliament— is quite relevant. It is a signal of concern about the inability of the Spanish political system to process technical critique, especially when it is uncomfortable for all involved.
We must ask ourselves whether Spain will be able to sustain a strong universal system, cohesive and attractive to its professionals and users, or whether we will witness, between passive indifference from some and selfishness from others, the SNS’s agony and a residual, good-for-those-with-no-other-option public health, dispensable for those who can pay. The answer largely determines the state of the Spanish welfare state. Time, this time, does not work in our favor.
Where the National Health System Gets Stuck Today
Let us start with governance of the system. The Ministry of Health retains a certain symbolic political responsibility toward citizens, but an extremely limited real capacity to govern public health —the competence of regulation and implementation lies with the autonomous communities— and healthcare provision —managed by the ACs—. It is an institutional tension that the 2020 pandemic dramatically exposed.
One of the most worrying phenomena of the SNS has been the progressive loss of technical and operational capacity of the Ministry of Health. I speak from direct knowledge. I knew those structures from inside, at a time when the Ministry and INSALUD had real possibilities for strategic planning, financing, evaluation, health information, territorial coordination and management. They were not perfect, but they were entities with accumulated knowledge and a strong will to perform their functions.
That institutional capital was progressively eroded for various reasons, such as the transfer process, budget cuts, the precariousness of its structures, and above all, the (lack of) political will. The knowledge and experience accumulated were not transferred to the periphery but simply disappeared, just as the prestigious “national corps” did.
Today’s Ministry of Health is not the impoverished heir of forty-five years ago, but a structurally different entity, with formal competencies that do not always find real means to exercise them or political will to do so. The COVID-19 pandemic showed how costly that loss was. A depowered ministry tried to coordinate seventeen health services with only formal authority. The result was evident to all.
On the weakness of the central government’s leadership also rests the problem of financing. In 2002 the traceability of state credit transfers to the ACs for health disappeared, as its earmarked nature was lost by Law 21/2001, which included a transitional guarantee that expired in 2004, and was completed by Law 22/2009. Until then, health funding arrived as a specific, nominative, and identifiable line within the public budgets, and its growth rate paralleled GDP. Since that date those transfers were integrated into the general system. The loss of this earmarked character appears transcendental in the assessments of all experts.
Yet the functional analysis of public health expenditure reveals another problem. Since the SNS’s founding, health spending has been concentrated at the hospital level. Hospital care consumes 60%, primary care 14%, and public health between 1% and 2%. This spending structure did not change with the economic recovery beginning in 2013, nor with the injection of an additional €36 billion into the system between 2013 and 2023, nor even with a pandemic in between (2020). Primary care remains anchored at 14% of health spending, while scientific and professional societies continue to recommend 25%. As for the evolution of public health spending, it is certainly notable: 1% of total health expenditure before the pandemic, 3% after the pandemic, and 1.7% currently. The lesson from the greatest pandemic of the century lasted only two budget cycles! We continue spending on public health less than a fifth of what we spend on tobacco and alcoholic beverages.
“Primary care remains anchored at 14% of health expenditure, while scientific and professional societies continue to recommend 25%”
In primary care is where the system “puts its life at risk.” No field better reflects the decline of the SNS, and no paradox is harsher: the more politicians and managers proclaimed its importance, the more its reality deteriorated. The “single management” —the integration of the management of health centers and their reference hospital under one leadership— did not make primary care the entry door to the system, but rather broadened the hospital’s reach. The pandemic added the telephone, which arrived as a remedy and stayed as a substitute, with its own waiting list. The average wait for an appointment with a family doctor now exceeds ten days —three times what it was two decades ago, according to the Health Barometer. Growing bureaucracy, overloaded agendas, loss of community dimension, and medical trainees fleeing to other specialties, when primary care is more needed than ever.
Mental health deserves a paragraph of its own, because it is where the gap between the proclaimed model and the hard reality is most evident. The 1986 LGS enshrined a community model that remains theoretically valid. But our SNS has half as many psychiatrists per capita as advanced European countries and a third of clinical psychologists (10 per 100,000 vs 20; 7 vs 21 per 100,000, respectively), with waits sometimes exceeding a year. Those who have means turn to private care. Those who do not receive delayed care. A new inequality that fractures the system’s foundations.
The pandemic also highlighted something that deserves equal emphasis: the main asset of the SNS remained its professionals. Their technical capability, ethical commitment, and resilience under extreme working conditions saved lives that a less well-equipped system could not have saved. I have been a practicing physician for decades, led the cardiology department of a reference hospital, and I know well what I am talking about when I say that the human and technical quality of SNS professionals is a public asset that the system cares little for, never evaluates, and almost never knows how to reward. The problem is that a health system cannot rely on extraordinary virtues to compensate for ordinary shortcomings. Nor can we discuss the pandemic response without expressly acknowledging nursing: nursing leadership, capable of shaping the whole organization with imagination and discipline, was decisive in crisis care, and nurses committed with efficacy far beyond their statutory obligations.
“The human and technical quality of SNS professionals is a public asset that the system cares little for, never evaluates, and almost never knows how to reward”
The current conflict in the health sector cannot be read merely as a wage dispute, although the compensation dimension is real and important. The core discontent runs deeper. As various professional organizations have noted, the heart of the conflict lies in “the deterioration of working conditions, the loss of clinical autonomy, sustained overload, and the perceived insufficient institutional recognition.” These are grievances that anyone who has practiced clinical medicine recognizes as legitimate, though incomplete, and that those who have managed health systems must accept as part of their institutional responsibility.
Let us also say what is not often said. The medical profession is very heterogeneous and its members’ interests are not only different; they are sometimes opposing. It is not the same for a clinician with reduced hours and private practice as for another with full-time exclusive dedication. It is not the same for someone who does many on-call shifts as for someone who cannot do them even if they want. The teacher, the surgeon, the microbiologist, or the family doctor. Professional career, incentives, recognition of exclusivity or incompatibilities have lost all meaning under equalizing unionism. Also, as in any negotiation, we should begin by removing euphemisms from the table. Demands are for “dignity” in compensation. Are not teachers’, judges’, or firefighters’ wages also “dignified”? Let us put on the table the real problems, demands, and pretensions. Otherwise, the conflict will close in on itself out of sheer exhaustion.
The health economy has a specificity that is systematically ignored: the supplier and the demander are the same agent. The doctor largely decides the spending that is generated. That differentiates health from any other public service and makes it akin to a company executive. It should be reflected in organization and remuneration, which should respond to the fourfold: agreement, commitment, autonomy, and responsibility. But the authorities of Finance and Public Function in the ACs have long insisted that a health service should be organized as an administrative office. And that’s how we are faring. In the recruitment of professionals, years of service and ties to the inviting center still predominate for positions whose content is rarely defined. In appointing heads of clinical units, publications are valued more than leadership, wasting talent and compromising management. And, in the end, managers must maneuver with cards marked by bureaucracy.
Trade unions, both “class” and “professional,” have historically promoted a certain stagnation of the SNS by criticizing truly differentiating incentives and resisting the introduction of center-management tools. Politicians, for their part, have lacked the grandeur and the institutional commitment necessary to place management responsibility beyond party politics and to plan for the medium and long term.
Spain has a relatively high number of doctors (4.6 per 1,000 inhabitants) —comparable to Germany and higher than France, the United Kingdom, or the OECD average (3.9)—; however, nurses are far fewer than in Western Europe and the OECD average (6.3 per 1,000 inhabitants versus 9.2), a deficit that has direct consequences for care organization and quality. This imbalance between doctors and nurses is one of the SNS’s major unfinished tasks, rarely present in public debate. That there is a little more than one nurse per doctor in Spain (ratio 1.4) while OECD average nearly doubles, is revealing. Nursing care is not only essential for healing our patients but also modulates the medical response to demand and is decisive in the link between patients and the health system.
To that, we must add that more than 30% of doctors are over 55, that employment in health care is precarious, which patients share, and that interruptions to continuity of care reached over 30% in some periods, and that certain specialties, particularly Family and Community Medicine, show growing coverage difficulties that foretell a serious care problem in the near future.
Spain has spent decades and substantial resources training excellent health professionals who then move to other European systems that pay better. According to the Health Ministry, the annual cost of specialized health training (MIR and equivalents) approaches €2,000 million. More than 9,000 new MIR enter annually and there are between 33,000 and 35,000 in simultaneous training. The emigration of medical specialists is a form of decapitalization that does not appear in public accounts, but is perfectly real. The costs and the excellence of Spanish specialized training —which, incidentally, is not available for other professions— should find some practical correspondence.
And finally, waiting lists, the most visible indicator of the SNS’s deterioration and the favorite instrument in political debate. They are also the most polished statistics in the system. According to data from the Health Ministry, as of December 31, 2025, 853,509 patients awaited a surgical intervention, with an average delay of 121 days and more than 21% of them waiting more than six months; another 4 million were waiting for a first specialist consultation. However, talking about “waiting lists,” in general, is only suitable in colloquial terms. Could someone tell me what a colon cancer surgery waiting list has in common with a bunion list? Some ACs include the patient on the surgical waiting list from diagnosis and others only record it when the preoperative study has been done. With those foundations, headlines and bloody partisan fights are manufactured. The Ministry itself has implicitly admitted the problem by announcing, together with the ACs, a new waiting-list information system, to replace the current one from 2003, in order to have homogeneous and comparable data.
“Waiting lists are the most visible indicator of the SNS’s deterioration and the favorite weapon in political debate”
All of the above explains the sustained growth of private insurance, which is, to a large extent, the response of citizens who do not find in the public sector the accessibility they need. In 2025 12.8 million people had private health insurance — 26% of the population, 200,000 more than a year earlier, according to the IDIS Foundation — with Madrid, Catalonia and the Balearic Islands at the forefront. It is worth noting, in the name of truth, that premiums remain affordable because the private insured still retains dual coverage, and serious or complex cases (and thus the most expensive) end up referred to the public system. Many patients say it aloud: “private for the day-to-day, public for the serious”.
Opinion data confirm the diagnosis and sharpen it. After a quarter-century of improvement, public opinion of the SNS has fallen steadily since 2019. In 2024, for the first time in the CIS series, those dissatisfied with health care outnumbered the satisfied for the first time. Yet, the deterioration centers on access and the image of the system, not so much on the quality experienced. Those who manage to be attended still rate the care they receive very highly; trust in professionals approaches a high mark. The preference for public care does not erode; it even grows for hospitalization and emergencies. The majority of the doubly insured, faced with a serious illness, would choose public health. Citizens confirm the wear but do not yet present a wholesale remedy. That nuance matters.
Because the process I describe feeds on itself. When the urban middle class overwhelmingly opts for dual coverage, the public system loses the legitimacy granted by the adhesion of those who can choose. And if nothing interrupts it, the outcome is known: a subsidized public health system. It is not a cataclysmic prophecy, but a trend already in progress, well known to other countries. The British NHS — with 7.4 million patients on waiting lists and nearly 3 million on long-term sick leave — now records the lowest level of citizen satisfaction since measurements began, and private insurance has grown by almost 1 million people in the last five years. Nordic systems, often cited as models, also see private insurance rising. The underlying problems — aging, chronic disease, rising expectations, costly technology, fiscal limits — are common across Europe. But others suffer them too; that is no excuse for not addressing our own.
What Reforms the National Health System Needs
There is no need to reinvent proposals. They have been formulated for years by those who know the system from within. Much of what follows comes from the document For a Re-foundation of the SNS, whose recommendations we still consider valid and now urgent. That statement, let us recall, received no response from either the Government or Parliament.
The document explicitly stated that the SNS, in its current reality, no longer properly responds to the spirit or the letter of the 1978 Constitution (CE) or the 1986 LGS, and that, therefore, it must be “refounded.” Beyond the term “refoundation,” which is debatable in its rhetorical burden, it raised technically precise questions of enormous relevance.
The general framework of those measures would be a state pact between the Government and the ACs, endorsed by the Cortes Generales.
The first proposal, and the condition for all others, is to reconstruct the governance of the system. That requires binding decisions by the Interterritorial Council of the SNS (CISNS) —the body that brings together the Ministry of Health and the health ministers of the ACs—, today a deliberative forum whose agreements are obeyed by each community only if and as they wish. No one advocates “centralizing” care. What is proposed is something different, and fully compatible with the autonomous state: that common decisions bind everyone, as do the decisions of any government body worthy of that name. And it requires, in parallel, that the State exercise the functions that the CE and the LGS assign to it. It should consider transforming the SNS into an entity with its own legal personality whose Governing Council is participated in by the State Administration and the ACs. We cannot look to the future without at least some imagination.
“The first proposal, and the condition of all others, is to rebuild the governance of the system”
Governing requires knowledge. That is why the 2020 document proposed a Health Information Office dependent on the CISNS and shared technical coordination agencies (central procurement, technology assessment, investment in high-cost technologies…). The pandemic showed that Spain did not have homogeneous, interoperable, real-time health information, but seventeen subsystems counting seventeen ways. Without common —and truthful— information there is no evaluation, no comparison between health services, and no accountability. The opacity of waiting lists is only the most visible example. We must rebuild the Ministry of Health’s technical capacity, not to return to “managing hospitals,” but to perform the functions that no one else can: medicines and medical devices, minimum technical requirements, general planning, supra-community statistics… and the High Inspection.
The second proposal is financial, and it has two faces. One is sufficiency: we cannot ask the SNS to meet the demands of the 21st century with the financing of the late 20th century. Remember that Spain spends less on health than the EU average. It is proposed to achieve public health expenditure as a share of GDP equal to the eurozone average, which would mean around one percentage point more of GDP. But it is not enough to merely increase budgets; we must also recover the earmarked nature of annual transfers from the State to the ACs for health, so that resources allocated to health go to health, identifiable and measurable, and not diluted in the budget of each community. We must give visibility to each Administration’s commitment to public health.
Access to all necessary medicines is an indispensable provision of our public health; their quality, safety, and an affordable price for the SNS must be guaranteed. The public sector spends about €24 billion annually on medicines (2024). To grasp the magnitude, imagine that with what the SNS spends on medicines in a year, the Armed Forces, the National Police, the Civil Guard, and the Penitentiary Institutions, plus the Congress and Senate, the King’s Household, the General Council of the Judiciary, the Constitutional Court, the Court of Auditors, the Ombudsman, and the Council of State could be fully funded. And there would still be a surplus.
The public sector should safeguard its capacity to produce medicines in crisis situations. There would be a push for transparency in cost of production, R&D, and prices of medicines, and a review of how prices for new medicines are set, tying them to those costs. Well, very recently, PSOE, PP, and Sumar agreed on a transitional amendment to Law 3/2026, of July 29 —Law on modifications of neonatal screening program rules—, an amendment processed as urgent and with little debate, concerning financing of medicines, which states that “The financing agreements reached, as well as the information arising from them or from their application, including the prices of awarding contracts for the supply of medicines entered into by public administrations, shall be confidential.” The fourth part of public health spending will remain hidden from citizens’ eyes. And by consensus.
The third is primary care; the “refoundation” document endorsed the experts’ recommendation to allocate at least 25% of health spending to primary care. Without a timetable that figure is purely rhetorical, so this commitment must be concrete. With the money must come the rest: real clinical management autonomy and complete multidisciplinary teams —social work, clinical psychology, and administrative capacity that frees physicians from the bureaucracy that consumes their schedules—, as well as the recovery of the community dimension, which was the hallmark of the 1984 reform, to know the population served and not merely dispatch the demand that knocks at the door.
The fourth is public health, the eternal Cinderella. Spain, as we have seen, dedicated before and after the pandemic a minuscule share of health spending to public health. A public health worthy of that name requires sufficient and steady funding, updated emergency response plans, and a preventive orientation that works in times of stability, not only in crisis management. It is the most profitable health investment there is, and one that no politician inaugurates.
The fifth is mental health. The proposal is stated with complete clarity: double its share in public health spending, from 5% to 10%, to finally implement the community model that the LGS enshrined in 1986. Any action plan without equivalent funding is a futile gesture.
The sixth, and perhaps the most challenging, is the new contract with professionals. In 2020 we called it the “social contract,” since it is not just about remuneration but about redefining the entire relationship between the system and those who operate it. Its elements are described above: employment stability; mandatory and incentivized work evaluation; selection by fit to the role, with pre-defined competencies; a margin of discretion (and responsibility) for the manager; effective recognition of exclusive dedication and the real differences within a heterogeneous workforce. And a reasonable temporary commitment to long-term ties to the public system after specialized training.
Within that contract there is a dedicated chapter for nursing. Correcting the imbalance between the number of doctors and nurses is not a corporate luxury: no strengthening of primary care or any chronic-care strategy will be credible without a sustained plan to expand nursing.
“It is not only about remuneration, but about redefining the whole relationship between the system and those who make it work”
And there is also an organizational chapter. A simplification of hospital and service organ charts is necessary. The structure of our hospitals cannot continue reproducing the apparatus of the body, with the patient moving from service to service. Almost a century ago there were hospitals organized around the patient and their clinical process. That spirit remains an aspiration today. Organizing care around the patient, and not around chairs and services, does not cost money: it costs overcoming inertia. It is also “vital,” for the patient and for the system, that there be a responsible consultant, perfectly known to the patient and their family.
The seventh proposal is health integration. An aging population, with dependence and multimorbidity, overwhelms the borders of strict health care. The pandemic taught this most cruelly in care homes, a no-man’s-land between two systems that did not speak to each other. Health and social services must plan together, share information, and respond simultaneously. Each year of delay is measured in avoidable suffering.
None of the above is original. The diagnosis is not lacking. The proposals are not lacking. What is missing is political will to bear short-term costs for long-term results, which is exactly what our electoral cycle punishes. That is why the SNS reform needs to take the form of a “state pact” between parties and with the ACs, shielding it from political change.
The SNS is not only defended in the street with electoral promises or banners, but, above all, in the health centers and hospitals, so that the patient feels that public health is worth it.
Ernest Lluch showed in the eighties that an ambitious health reform was possible in Spain. Forty years later, the question is not technical, but political: whether someone will be willing to try again before the SNS’s agony becomes irreversible. Patients, it is known, cannot wait indefinitely. The health systems, either.
