European Observatory on Health Systems and Policies


Health Systems in Transition (HiT) profile of Spain

5. Provision of Services

Chapter summary

  • Some of the reforms implemented before 2010 and some of the strategies developed in the late 2000s have been observed to deepen in the last 5 years, although with the inexorable hindrance of the economic downturn.
  • New 2013 taxes on tobacco and alcohol have been implemented and the population-based screening for colorectal cancer is notably increasing coverage, while slowly reducing regional inequalities in its application.
  • Primary care remains a consolidated core element of the SNS; the increasing financial gap compared with secondary care and some workforce structural flaws may challenge its central role in the long-term.
  • There are important concerns regarding secondary care, particularly hospital care, including high rates of low-value procedures, large differences in elective surgery across health care areas, and systematic differences in access to some evidence-based interventions.
  • The large variation in prescriptions across ACs, along with their uneven growth, raises concerns on the impact on the overall efficiency of SNS allocation. Nonetheless, efforts since 2010 to increase evidence-based prescription, either looking for the best therapeutic options or avoiding inappropriate indications, have been developed.
  • The National System for the Assistance of Dependent People (namely, SAAD) has been developed in the last decade, currently assisting almost 900 000 people. The relatively low coverage (29% of those entitled to receive benefits are not yet covered) and concerns on the sustainability of the current financing system cast shadows on its long-term development.

5.1 Public health

Although there have been new developments in the national regulation of public health (see below), no major novelties in the provision of public health services have been experienced in Spain since 2010. Competences on public health local planning and provision were transferred to all 17 ACs between 1979 and 1981. Although with some variation, public health within ACs has a dedicated structure where a health authority, usually a general directorate, ensures the enforcement of the regulations passed to support public health policies, throughout the workforce of public health inspectors, and holds the executive planning role for public health services and the provision of public health surveillance and monitoring activities (health status, health determinants and health risks). The health authority also acts as the regional hub of the national network for epidemics surveillance and those care settings that provide population-based screening programmes. Finally, the health authority supports non-health-care providers in the development of prevention and health promotion programmes mediated by schools or nongovernmental organizations. In coordination with the regional health authorities, municipalities are critical public health agents in sanitation and environmental issues and, in larger villages, in food safety control, slaughter of animals, and in local health promotion programmes.

Interestingly, core public health agents in the SNS are primary care doctors and nurses. The bulk of preventive medicine and health promotion activities (for example, infant and older people vaccination programmes, primary and secondary prevention of noncommunicable diseases, opportunistic screening activities, health education activities) are integrated as part of their normal activity.

Besides the public health activities developed at regional level, the Spanish Ministry of Health (MSSSI), through the General Directorate of Public Health, has responsibility for certain public health tasks, such as international health activities (for instance, control and surveillance of risks derived from international movement of commodities and passengers), food safety regulation, the system of alerts for health emergencies and, notably, the coordination of the 17 public health regional Departments of Health and INGESA. As in many SNS instances, public health policies are coordinated in the context of the Interterritorial Council, and particularly, throughout the working groups that compose the Commission for Public Health, including: (a) the committee on environmental health; (b) the working group on epidemiological surveillance; (c) the working group on occupational health; (d) the working group on health promotion; and (e) the committee on vaccination programmes.

Nationwide, public health efforts since 2010 have been on developing regulatory provisions (see section 6.1.6 Reforms on public health) and providing guidance aimed at addressing health determinants. Some notable actions include the following.

  • The Ministry of Health issued Law 42/2010 on tobacco consumption and market regulation, expanding the provisions of the previous “anti-tobacco” 2005 Law (Law 28/2005), increasing the protection of minors and non-smokers and prompting health institutions, particularly primary health care, to implement smoking cessation programmes (see section 1.4 Health status and section 6.1.6 Reforms on public health).
  • The working group on the NAOS strategy (AECOSAN, 2017) (in Spanish, Strategy on nutrition, physical activity and obesity prevention), consolidated by Law 17/2011, has been working on the elaboration of indicators for the assessment of the NAOS strategy (AECOSAN, 2011), the monitoring of child obesity (AECOSAN, 2016) and the development of accreditation criteria for those schools interested in the implementation of health promotion activities on nutrition, physical activity and obesity prevention (AECOSAN, 2015).
  • In the context of the local development of the strategy for health promotion and prevention approved in 2013 (MSSSI, 2014c), the SNS Interterritorial Council approved in January 2015 the Guide for the local implementation of the SNS Strategy on Health Promotion and Prevention (MSSSI, 2015f) whose main pillars are the leadership of municipalities and their intersectoral action.
  • The Ministry of Health also chartered a new regulation (RD 843/2011) to define requirements and quality criteria for the providers of preventive services in the context of occupational health.
  • The Ministry of Finance has implemented two reforms on taxation affecting alcohol and tobacco products – through the first reform in 2013, taxation increased 10% for alcohol (with the exception of wine and beer) and 3% for a pack of cigarettes; the second wave, implemented in 2017, implies 5% increase in alcoholic beverages, 2.5% increase for a pack of cigarettes and 6.8% increase in rolling tobacco.
  • Finally, Law 33/2011 on Public Health issued the principles and actions to include “Health in All Policies” in the institutional action on health, and sought to update and upgrade the coordination mechanisms among the 17 health authorities and INGESA, essentially in terms of epidemic surveillance and control, and the provision of common benefits (for example, common vaccination calendar, common neonatal screening tests or colorectal cancer screening).

Box5.1 provides the assessment of the effectiveness of public health interventions.

After assessing the report carried out by the Technical Committee on Vaccination Programmes, the Public Health Commission within the Inter-Territorial Council for the National Health System has agreed to modify the standards for meningococcal meningitis vaccination.

In particular, the current meningitis C vaccination at 12 years old will be replaced by the one-dose tetravalent meningococcal serogroups ACWY, due to the increasing incidence of serogroups W and Y. This modification has translated into a change in the common vaccination calendar for the whole NHS.

Besides, the Commission decided to adopt the non-inclusion recommendation of the Technical Committee for Meningitis B vaccination, given the low incidence of the disease and the uncertainty about its effectiveness, protection of the duration and the of herd immunity. Yet, the meningococcal serogroup B vaccination will keep the current indications in high-risk population subgroups (e.g. low immunity or previous meningococcal infection) or in case of a meningitis B outbreak.

More information (in Spanish):

The Spanish Ministry of Health has launched a new digital awareness campaign advocating the high value of vaccination. Under the motto ‘Vaccines save lives’ (in Spanish: “V de vacuna, V de vida. Las vacunas salvan vidas”), this campaign is addressed to the general public in response to the misleading information provided by the growing anti-vaccination movement, which may lead to erroneous believes and low confidence in vaccination benefits. The campaign aims at reinforcing the message that vaccines are useful and necessary throughout the whole life.

In Spain, vaccines included in the National Health Services calendar are well above the 90% of coverage, both in prime and boost doses. This is not the case, however, for flu vaccination, with coverage below 60% of eligible patients.

More information (in Spanish):

The Spanish Ministry of Health and the Ministry of Science have released the campaign #coNprueba (, aimed to raise awareness on the risks of pseudoscience and therapies not supported by scientific evidence, with the final objective of protecting the health of the population.

A plan has been set aimed at excluding the use of pseudoscience in health settings and as well as its teaching in academic centres. In addition, the Plan will spread actions to improve population’s literacy and promote critic and rational thinking among students and will launch a communication campaign against online hoaxes and misleading advertising about health and science.

In this context, the Spanish Network for Health Technology Assessment (REDETS) has been mandated to assess the efficacy and safety of a list of 130 therapies. First results revealed no evidence available for 73 of them; the remaining 66 therapies are still under assessment.

More information (in Spanish):

The second National Plan on Antibiotic Resistance (PRAN, in Spanish), a joint initiative of the Ministries of Health and Agriculture, has been launched in the last Interterritorial Council of the National Health System, held the 4th of March. The development of this new Plan has involved all the 17 Autonomous Communities, 8 Ministries, 70 Scientific Societies, and up to 300 experts.

Under the coordination of the Spanish Agency of Medicines and Medical Devices (AEMPS), this 2019-2021 PRAN aims at reducing antibiotic consumption in both, human and animal care, and includes strategies on surveillance, control, prevention, research, training and communication of risks.

The current plan builds on the 2016 PRAN achievements that got a 4.3% reduction in antibiotic consumption, breaking the growing trend observed since 2012, and that developed a surveillance network of dedicated labs specialized in resistant microorganisms.
As a matter of fact, Spain is one of the European countries with the highest antibiotic consumption and around 3,000 people die each year in the country as a consequence of hospital-acquired infections attributable to antimicrobial resistance. 

More information (in Spanish):

In the last Interterritorial Council held in November 15th, the Ministry of Health and its counterparts in the Autonomous Communities (that is, the Health Authorities at regional level) agreed a common vaccination calendar for all the Spanish National Health System, which covers the prevention of infectious diseases in pregnant women, childhood and adolescence, adult life and threats for the elderly people.

It is the first common calendar at national level covering all life time, since the previous ones only covered childhood, excluding population older than 18 and specific risk groups.

The vaccination calendar comprises the prevention of 14 infectious diseases; thus, it includes 17 shots for children between 0 and 14 years old (poliomyelitis, diphtheria-tetanus-pertussis, Haemophilus influenza b, measles-mumps-rubella, hepatitis B, meningitis chicken pox, human papillomavirus and pneumococcal vaccine), two per each pregnant woman (flu and whooping cough) and two additional for people aged 65 and older (diphtheria-tetanus-pertussis and pneumococcal vaccines), besides the yearly flu vaccination.

The National Vaccination Programme includes vaccination recommendations for patients with some conditions as immunosuppression, cardiovascular diseases, diabetes or hepatopathies.

More information (in Spanish):

The Inter-territorial Council of the Spanish National Health System held in April 24th has approved the Ministerial Order SSI/425/2018 (MO), which establishes the procedure of registration and authorization of homeopathic remedies, as regulated by Royal Decree (RD) 1345/2007.

According to the MO, all homeopathic products have three months to register in the Spanish Agency for Medicines and Medical Devices (AEMPS). After registration, interested companies need to request a marketing authorisation, which requires AEMPS to guarantee that the product owns sufficient quality and safety as established by RD 1345/2007.

Homeopathic products obtaining the marketing authorization will be labelled as “medicines without therapeutic approved indication”, without requiring proof of their efficacy. Nonetheless, for a product to be authorized for specific indications, it must follow the regular procedure to demonstrate its efficacy, as any other allopathic drug.
Furthermore, from now on the MO establishes a new annual maintenance fee for the authorised homeopathic products.

More information (in Spanish):

Ministerial Order SSI/425/2018:

Royal Decree 1345/2007:

Royal Decree 1/2015 detailing fees:

Health Ministers from Spain and Portugal have signed a non-normative agreement the 10th July 2017, to reinforce the collaboration between both countries in health issues.

Key elements of the agreement are related to environmental,
entomological and epidemiological surveillance. Both countries will collaborate to identify cross-border risk areas where disease vectors are likely to be found, as well as to reduce and control these vector populations.

Portuguese and Spanish ministers also have made a declaration of intent on centralized purchasing, funding and price setting for drugs. Experts from both countries will share their experiences and will perform a pilot project with a selected biosimilar drug, to design a common procedure that will be evaluated in terms of its results.

More information (in Spanish):