Spain’s healthcare system continues to perform efficiently, but is experiencing increasing deterioration and marked territorial disparities, according to a new report from the Centre for Social Studies, Training and Analysis (CEU-CEFAS). The study, “The Spanish Healthcare System: Strengths, Weaknesses and Improvements,” states that Spain still has one of the world’s most efficient health systems, delivering excellent results. However, it also reveals signs of structural exhaustion, including record waiting lists, widening regional gaps and declining productivity.
An efficient model delivering outstanding results
Despite its challenges, the report highlights that Spain’s healthcare system continues to provide high-quality care, achieving exceptional health outcomes while spending below the European average.
Healthcare spending: In 2023, Spain allocated 9.6% of its GDP to healthcare (combining public and private spending), compared to over 10% on average in Western Europe.
Efficiency: With lower per-capita spending than major European nations, Spain achieves stronger overall health outcomes, demonstrating high comparative efficiency.
Life expectancy: Spain maintains one of the highest life expectancies in the world (83.8 years in 2023, expected to exceed 84 years in 2024), surpassing France, Germany and the United Kingdom. The Madrid region leads the global rankings, with a life expectancy of 85.1 years in 2023, making it the capital city with the highest life expectancy in the world.
The report attributes part of this success to a mixed public-private model, in which 26% of total healthcare expenditure comes from the private sector. This has helped ease pressure on the public system and ensured faster and complementary access to medical care.
Signs of deterioration: longer wait times and less equity
The study warns that Spain’s healthcare system is entering a phase of wear and tear, clearly reflected in key indicators. According to the latest data analysed:
Surgical waiting lists have reached an all-time high, with over 850,000 patients awaiting procedures, twice as many as in 2010.
The average waiting time exceeds 120 days, with major disparities among regions: fewer than 70 days in Madrid or the Basque Country versus more than 160 in Andalusia or Castilla-La Mancha.
Waiting times for specialist consultations have also surged: more than 100 days on average, compared with 60 a decade ago.
The report stresses that the decentralised management of healthcare across 17 autonomous communities has generated significant inequalities in quality, access and efficiency. In addition, an ageing population and increasing immigration are placing added strain on the public system: the share of foreign-born residents in Spain has risen from 2.7% in 1996 to 19.6% by mid-2025, and the vast majority rely exclusively on public healthcare.
Healthcare workers: vocation overshadowed by precarious conditions
The report also highlights a growing exodus of medical talent, particularly among young doctors. Low salaries, unstable employment and heavy workloads have driven thousands of Spanish professionals to migrate to other European countries for better opportunities. Spain ranks 19th among OECD countries in medical remuneration, despite being one of the nations with the highest patient pressure per capita.
Proposals for a sustainable future
The study presents a series of measures to reverse the deterioration and guarantee the long-term sustainability of Spain’s healthcare system, including:
Revising the regional management model, seeking as much as possible the recentralisation of public healthcare and the sharing of resources across regions.
Strengthening public-private collaboration to optimise resources and reduce waiting lists.
Achieving net zero immigration until Spain approaches full employment, due to its impact on healthcare (and housing). Without the arrival of several million foreign immigrants in a country with millions of real unemployed citizens, waiting list problems would be considerably smaller and public healthcare spending significantly lower.
Public healthcare cannot be free of charge for people without a Spanish health card or legal residence permit. Emergency care should never be denied, but it should not be free for those without legal residency.
Ensuring that public healthcare users are aware of the real market cost of the services they receive. Issuing a pro-forma invoice (whether payable or not) reflecting the cost of treatments and medications would help educate citizens, facilitate co-payments and discourage “overuse” of a system widely perceived as free.
Progressively reducing civil-service status within public healthcare. Universal, affordable healthcare does not require all medical professionals to hold lifelong civil-servant status, which tends to reduce productivity compared with private-sector employment.
Tax deductions on personal income tax (IRPF) for private healthcare spending, since private consumption reduces patient load and costs for the public system.
Implementing active policies to retain healthcare talent, through salary incentives, career development and later retirement for highly skilled doctors.
Boosting preventive and personalised medicine, with greater investment in technology, AI and primary care.
Promoting health education and introducing co-payments for medical visits, encouraging a more rational use of public resources.
Increasing transparency and oversight in productivity, outcomes, costs and efficiency of regional health services.
Allowing pharmacies to carry out simple diagnostic tests and adjust medication dosage, enhancing accessibility and efficiency.
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