Spanish National Health System

The Spanish National Health System ( es, Sistema Nacional de Salud, SNS) is the agglomeration of public healthcare services that has existed in Spain since it was established through and structured by the ''Ley General de Sanidad'' (the "Health General Law") of 1986. Management of these services has been progressively transferred to the distinct autonomous communities of Spain, while some continue to be operated by the National Institute of Health Management (''Instituto Nacional de Gestión Sanitaria'', INGESA), part of the Ministry of Health and Social Policy (which superseded the Ministry of Health and Consumer Affairs—''Ministerio de Sanidad y Consumo''—in 2009). The activity of these services is harmonized by the Interterritorial Council of the Spanish National Health Service (''Consejo Interterritorial del Servicio Nacional de Salud de España'', CISNS) in order to give cohesion to the system and to guarantee the rights of citizens throughout Spain.

Article 46 of the ''Ley General de Sanidad'' establishes the fundamental characteristics of the SNS:

* a. Extension of services to the entire population.
* b. Adequate organization to provide comprehensive health care, including promotion of health, prevention of disease, treatment and rehabilitation.
* c. Coordination and, as needed, integration of all public health resources into a single system.
* d. Financing of the obligations derived from this law will be met by resources of public administration, contributions and fees for the provision of certain services.
* e. The provision of a comprehensive health care, seeking high standards, properly evaluated and controlled.

Antecedents to the SNS in Spain

Public intervention in collective health problems has always been of interest to governments and societies, especially in the control of epidemics through the establishment of naval quarantines, the closing of city walls and prohibitions on travel in times of plague, but also in terms of hygienic and palliative measures. Al-Andalus—Muslim-ruled medieval Spain—was distinguished by its level of medical knowledge relative to the rest of Europe, particularly among the physicians of the Golden age of Jewish culture in Spain. In the years after the ''Reconquista'', the ''Real Tribunal del Protomedicato'' regulated the practice of medicine in Spain and in its colonies. However, the system of medical faculties at the various universities was very decentralized. Surgery and pharmacy were quite separate from medicine and were considerably less prestigious; the systems of Galen and Hippocrates dominated medical practice during most of the era of the '' Antiguo Régimen''.

Medicine was one of the principal fields of activity for the '' novatores'' of the late 17th century, but their initiatives were individualized and localized. There is some continuity from their work to the broader work during the Age of Enlightenment, such as through the Colegio de Cirugía de San Carlos ("San Carlos College of Surgery") in Madrid. At the beginning of the 19th century, the Balmis Expedition (1803) to administer the smallpox vaccine throughout the Spanish colonies was a public health undertaking of unprecedented geographical scope.

The Cortes of Cádiz debated a sanitary code (the ''Código Sanitario de 1812''), but nothing was approved due to lack of scientific and technical consensus about the actions to be undertaken. During the bienio progresista, the Law of 28 November 1855 established the basis for a General Health Directorate (''Dirección General de Sanidad''), which was created a few years later and which would last into the 20th century. The Royal Decree of 12 January 1904 approved the General Health Instruction (''Instrucción General de Sanidad''), which altered little of the 1855 scheme besides the name; the name would later change to General Inspectorate of Health (''Inspección General de Sanidad'').

After the Spanish Civil War, the ''Ley de Bases de 1944'' perpetuated this . The Law of 14 December 1942 create a system of obligatory health insurance under the already extant National Insurance Institute (''Instituto Nacional de Previsión'', INP). The system was based on a percentage tax linked to employment. This was further modified by the General Law of Social Security (''Ley General de la Seguridad Social'') in 1974, toward the end of the Franco regime. Social Security had taken on an increasing number of diseases within its package of services, as well as covering a larger number of individuals and communities.

The General Health Law (''Ley General de Sanidad'') of 25 April 1986 and the creation of Health Councils (''Consejerías de Sanidad'') and a Ministry of Health, fulfilled the mandate of the Spanish Constitution of 1978, in particular Articles 43 and 49 which made protection of health a right of all citizens, and Title VIII, which foresaw that purview over matters of health would devolve to the autonomous communities.

Laws regulating the Spanish National Health System

The General Health Law of 1986

The General Health Law of 1986 (''Ley 14/1986 General de Sanidad'') was formulated on two bases. First, it carries out a mandate of the Spanish Constitution, whose articles 43 and 49 establish the right of all citizens to protection of their health. The law recognizes a right to health services for all citizens and for foreigners resident in Spain.

Second, Title VIII of the Constitution confers upon the autonomous communities broad purview in matters of health and health care. The autonomous communities have first-order importance in this area, and the law permits devolution of these functions from the central government to the autonomous communities, in order to provide a health care system sufficient for the needs of their respective jurisdictions. Article 149.1.16 or the Constitution, a further basis for the present law, establishes substantive principles and criteria that allow general and common characteristics to be consistent throughout the new system, providing a common basis for health services throughout Spanish territory.

The administrative device set up by the law is the National Health System. The presumption underlying the adopted model is that in each autonomous community, authorities are adequately equipped with necessary territorial perspective, so that the benefits of autonomy do not conflict with the needs of management efficiency.

Thus, the various health services fall under the responsibility of the respective autonomous communities, but also under basic direction and coordination by the central state. The respective health services of the autonomous communities would gradually realize a transfer of health resources from the central government to the autonomous communities.

Law of Cohesion and Quality (2003)

The General Health Law was complemented in 2003 by the Law of Cohesion and Quality of the National Health System (''Ley 16/2003 de cohesión y calidad del Sistema Nacional de Salud''), which maintained the basic lines of the General Health Law, but modified and broadened the articulation of that law to reflect existent social and political reality. By 2003, all of the autonomous communities had gradually assumed purview in matters of health and had established stable models to finance the assumed purview. Meanwhile, in the 17 years since the original law, Spanish society had undergone many cultural, technological and socioeconomic changes that affected people's ways of life and affected the country's patterns of disease and illness. These posed new challenges to the National Health System.

Therefore, the 2003 law establishes coordination and cooperation of public health authorities as a means to ensure citizens the right to health protection, with the common goal of ensuring equity, quality and social participation National Health System. The law defines a core set of functions common to all of the autonomous health services. Without interfering with the diversity of forms of organization, management and services inherent in a decentralized system, it attempts to establish certain basic, common safeguards throughout the country. This law attempts to establish collaboration of public health authorities with respect to benefits provided, pharmacy, health professionals, research, health information systems, and the overall quality of the health system.

Toward these ends, the law created or empowered several specialized organs and agencies, all of which are open to the participation of the autonomous communities. Among these are the Agency of Evaluation of Technologies (''Agencia de Evaluación de Tecnologías'', Spanish Agency of Medicines and Medical Devices (''Agencia Española de Medicamentos y Productos Sanitarios''), the Human Resources Committee (''Comisión de Recursos Humanos''), the Committee to Assess Health Research (''Comisión Asesora de Investigación en Salud''), the Charles III Institute of Health (''Instituto de Salud Carlos III''), the Institute of Health Information (''Instituto de Información Sanitaria''), the Quality Agency of the National Health System (''Agencia de Calidad del Sistema Nacional de Salud'') and the Observatory of the National Health System (''Observatorio del Sistema Nacional de Salud'').

The basic organ of cohesion is the Interterritorial Council of the Spanish National Health Service (''Consejo Interterritorial del Servicio Nacional de Salud de España''), which has great flexibility in decision making, as well as mechanisms to build consensus and to bring together the parties taking such decisions. A system of inspection, the ''Alta Inspección'', assures that accords are followed.

Royal Decree-Law of Urgent Measures to Guarantee the Sustainability of the Sistema Nacional de Salud and Improve the Quality and Security of its Prestations (2012)

The Royal Decree-Law 16/2012 was introduced on April 20, 2012. It puts into law severe cuts in the Spanish National Health System, including the following:
* Refusal to give assistance to unregistered foreigners (in effect from September 1, 2012). This hasn't been applied by all the comunidades autónomas.
* Increase of the percentage of medicines paid by the user:
** Senior citizens didn't pay for medicines before the reform, but now they pay 10% (limited to €8/month if their income is ≤€18,000 a year, €18/month if their income is >€18,000 and ≤€100,000 a year, or €60/month if their income is >€100,000 a year).
** Workers now pay 40% if their income is ≤€18,000 a year, 50% if their income is >€18,000 and ≤€100,000 a year, or 60% if their income is >€100,000 a year.

Governing agencies

Ministry of Health and Social Policy

The Ministry of Health and Social Policy develops the policies of the Government of Spain in matters of health, in planning and delivery of services, as well as exercising the purview of the General Administration of the State to assure citizens the right to protection of their health. The ministry has its headquarters on the Paseo del Prado in Madrid, across the street from the Museo del Prado.

The Royal Decree 1041/2009 of 29 June lays out the basic organic structure of the Spanish Ministry of Health and Social Policy. From the date of that decree, the new ministry assumed the functions of, and superseded the former Ministry of Health and Consumption (''Ministerio de Sanidad y Consumo'') and Secretary of State for Social Policy, Family, and Attention to Dependency and Disability (''Secretaría de Estado de Política Social, Familia y Atención a la Dependencia y a la Discapacidad'').

The objective of this reorganization is to reinforce the role of the single ministry as the instrument of cohesion for the National Health System (SNS), adding to the portfolio of the Secretary General of Health purview in matters of the quality of the SNS by adding to it the Agency of Quality of the National Health System (''Agencia de Calidad del Sistema Nacional de Salud'') and the General Directorate of Advanced Therapies and Transplants (''Dirección General de Terapias Avanzadas y Trasplantes'').

Interterritorial Council of the Spanish National Health Service

The General Health Law of 1986 created the Interterritorial Council of the Spanish National Health Service (''Consejo Interterritorial del Servicio Nacional de Salud'', CISNS) as the organ of general coordination in matters related to health between the central State and the autonomous communities who were given authority in health matters under that law. It is jointly composed, and coordinates the basic lines of health policy in matters affecting contracts; acquisition of health and pharmaceutical products, as well as other related goods and services; as well as basic health personnel policies.

The 2003 Law of Cohesion and Quality of the SNS introduced significant changes in the composition, functioning, and purview of the CISNS. Under this law, the CISNS functions variously as a plenary body, by delegated committees, through technical commissions, and through work groups. It meets as a plenary body at the initiative of its president or at the initiative of one-third of its members; plenary meetings occur at least four times a year. To some extent, this is a formality: resolutions from CISNS commissions are typically adopted by consensus. Cooperation agreements to conduct joint health actions are formalized in CISNS agreements.

Under the Law of Cohesion, CISNS functions mainly through the adoption of and compliance with joint accords, through the political use of the plenary sessions, with each member making an uncompromising defense of the interests of its region.

Presentations, committees, and working groups have been very important, some more than others. Important committees include:
* Public Health Committee (''Comisión de Salud Pública'')
* Permanent pharmacy committee (''Comisión permanente de farmacia'')
* Scientific-technical committee of the National Health System (''Comisión científico-técnica del sistema Nacional de Salud'')
* Committee to monitor the health cohesion fund (''Comisión de seguimiento del fondo de cohesión sanitaria'')
* Permanent committee on insurance, funding, and benefits (''Comisión permanente de aseguramiento, financiación y prestaciones'')
* Committee against gender violence (''Comisión contra la violencia de género'')
* Transplant committee (''Comisión de trasplantes'')

Articles 69, 70 and 71 of the Law of Cohesion regulate the principal functions of the Interterritorial Council of the SNS. The principal aspects of the Interterritorial Council are:

The Interterritorial Council is constituted by the Minister of Health and Consumer Affairs ow of Health and Social Policy who holds its presidency, and by the Councilors with purview over matters of health of the autonomous communities. The vicepresidency of the body will be fulfilled by one of the Councilors with purview over matters of health of the autonomous communities, elected by all of the Councilors who make up the body.

The CISNS will come to know, debate among other things, and, as appropriate, make recommendations on the following matters:

* a) The development of the portfolio of services corresponding to the Catalog of Services of the National Health System, as well as its actualization.
* b) The establishment of health services complementary to the basic services of the National Health System on the part of the autonomous communities.
* c) Minimal guarantees of safety and quality for the authorization of the opening and placing into function of the health centers, services and establishments.
* d) The general and common criteria for the development of collaboration between pharmacy offices.
* e) The basic criteria and conditions of the convocations of professionals to assure their mobility throughout the State.
* f) Declaration of the necessity to realize coordinated actions in matters of public health to which this law refers.
* g) General criteria for the public financing of medicines, medical products and their variables.
* h) Establishment of criteria and mechanisms in order to guarantee at all times the financial sufficiency of the system.

The prior functions shall be exercised without prejudice to the legislative purview of the Cortes Generales and, as appropriate, the norms of the General Administration of the State; likewise the normal developmental, executive and organizational purview of the autonomous communities.

Purview of the autonomous communities in matters of health

Article 41 of the General Health Law establishes that:
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* The public policies and actions foreseen in this Act which are not expressly reserved for the state will be deemed to have been delegated to the autonomous communities.

The State finances, through general taxes, all health benefits and a percentage of pharmaceutical benefits. This tax is shared among the several autonomous communities according to various sharing criteria now that the communities are responsible for health in their respective territories.

Each year the CISNS, after deliberation, establishes the portfolio of services covered by the National Health System, which is published by a Royal Decree of the Ministry of Health. Each autonomous community then establishes its respective portfolio of services, which includes at least the service portfolio of the National Health System.

Purview of local governments in matters of health

Article 42 of the General Health Law sets out that '' ayuntamientos''—municipal governments—have the following responsibilities with respect to health, without prejudice to the purview of other public administrative bodies:

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