Spain moves towards a more resilient health coverage policy during COVID-19

The Government of Spain is introducing new exemptions from co-payments (user charges) for outpatient prescriptions – a reform expected to benefit around 6 million people. From 1 January this year, low-income pensioners, moderately and severely disabled children, and households receiving child benefits no longer have to pay out of pocket for prescribed medicines.

The Government has also allocated €49 million to be spent on expanding dental care coverage. Both changes aim to reduce inequalities in access and strengthen financial protection, in line with WHO recommendations on how countries can make progress towards universal health coverage.

Reforms target key gaps in health coverage

Under Spain’s national health system, almost all covered services are free at the point of use. Outpatient medicines are a key exception. Children and adults are required to pay co-payments of up to around €4 per medicine prescribed for most chronic conditions and, for all other prescribed medicines, co-payments ranging from 10% to 60% of the price (depending on household income and pension status). Mechanisms to protect people have been limited, especially for low-income people of working age.

Although there are no co-payments for covered dental services, the range of dental services in the publicly financed benefits package is very narrow – mainly preventive services for children and pregnant women, extractions, and emergency interventions.

This means that almost all dental care is paid for out of pocket, leading to financial hardship for some households and causing others to forego dental care altogether. The share of the population reporting unmet need for dental care due to cost, distance or waiting time is higher in Spain than the European Union average, and is marked by substantial income inequality.

The legacy of austerity

Spain was hit hard by the financial and economic crisis that began in 2008. Policy changes to health coverage introduced in 2012, in the context of the European Stability Mechanism, created access barriers for many people. The linking of entitlement to publicly financed health care to payment of social security contributions, for example, restricted access for undocumented migrants and people working in the informal economy. The introduction of co-payments for outpatient prescriptions for pensioners, and an increase in these co-payments for children and employed adults, also increased financial pressure on certain groups.

The 2012 reforms kept important protective mechanisms in place – notably, exemptions from co-payments for some social beneficiaries and reduced co-payments for a wide range of medicines for chronic conditions. They also introduced new protections, such as an annual income-related cap on co-payments for pensioners and exemptions for unemployed people who are no longer entitled to unemployment benefits.

In spite of these carefully considered safeguards, however, the 2012 reforms increased access barriers, particularly for people in vulnerable situations. In the most recent Barómetro Sanitario, an annual survey of citizen perceptions of the Spanish health system, 3% of the population reported not being able to access prescribed medicines for financial reasons.

Building back better

In 2018, the universality of Spain’s health system was restored, granting “the right to health protection and health care, under the same conditions, to all people who are in Spain”. In 2020, exemptions from co-payments for outpatient prescriptions were extended to beneficiaries of a new guaranteed minimum income scheme. Spain is also trying to remove administrative barriers to access that undocumented migrants and other disadvantaged groups of people still face.

Taken together, these changes do not just aim to return to the pre-2012 situation – they are likely to move Spain several steps forward on the path to universal health coverage.

COVID-19 increases the need to tackle inequalities

These types of protective measures are particularly important in the context of COVID-19. The health, social and economic consequences of the pandemic disproportionately affect disadvantaged households. Learning from the experience of the 2008 financial and economic crisis, responses to the pandemic must involve urgent action to mitigate already-sharp increases in inequality.

Spain’s reforms are taking place in spite of the fiscal constraints posed by COVID-19. By taking steps to establish a resilient coverage policy – one that ensures people do not lose health coverage when their living standards or health decline and that entitles them to enhanced protection when they are in vulnerable situations – Spain sets an example for the rest of Europe to follow.

New WHO analysis of financial protection in Spain out soon

The WHO Barcelona Office for Health Systems Financing is working with a team of Spanish experts to assess the extent to which people living in Spain experience financial hardship when they use health services, including medicines. Underpinned by the European Programme of Work, which holds universal health coverage as one of its 3 priorities, this new analysis will help to identify the health services most likely to lead to financial hardship, the people most likely to be affected and the root causes of gaps in coverage.