Travellers to Spain and expats living in the country will find the Spanish healthcare system offers a range of quality public as well as private services. The Spanish National Healthcare System, Instituto Nacional de la Salud, is principally funded by taxation, guaranteeing universal healthcare access to Spanish nationals and most Spanish residents. Under this system, basic services are free, but patients sometimes need to contribute, for example, paying a proportion of the cost of prescriptions. Dental and ophthalmological services are not covered by this system.

The Spanish healthcare system is increasingly decentralised to the 17 Autonomous Communities, with the ability to plan, change and upgrade their health infrastructure according to the needs of local residents.

Although the Spanish population is among the world’s healthiest, with an average life expectancy of 83 years and a low rate of heart disease, issues sometimes arise over co-ordination and varying standards of care between the autonomous communities. To improve this, efforts are underway to increase shared access to digital patient health information.

Private healthcare is less widely used by Spanish nationals, but is preferred by those looking for value-added services such as private rooms and keen to avoid the sometimes-long waiting lists for specialist doctors.

Private providers fill healthcare gaps

About 440 of Spain’s approximately 780 hospitals are privately run and perform well, with particular excellence in certain specialties, including ophthalmology. The private healthcare sector in Spain employs more than 260,000 professionals and represents 3.5 per cent of Spanish GDP.

Geographically, the highest concentration of highly ranked private hospitals are found in Madrid and Barcelona, with the leading private hospital group in Spain being Quirónsalud, a network of 48 hospitals spread across 13 regions. The hospital group sees more than 30,000 international patients a year and has over 35,000 employees.

Other big players include HM Hospitales, Vithas, Hospiten, and the Quiron group, whose large network of private hospitals in Spain includes the Hospital Quiron and Centro Médico Teknon, both in Barcelona. As expected, Catalonia has the largest healthcare market among the autonomous regions for both total and private expenditure, and the highest rate of people enrolled in private insurance schemes.

Expats who work in Spain and make social services contributions are entitled to the same public healthcare benefits as locals. But for those whose situation means they are not entitled to public healthcare, private health insurance is necessary.

Many of the world’s largest health insurance providers serve Spain, including Allianz Care, Bupa Global, Cigna Global, Globality Health, and APRIL International. Premium costs are very reasonable, starting at around €50 per month.

Healthcare accreditation goes virtual during Covid

Many private healthcare services in Spain are accredited by the US-based Joint Commission International (JCI), which has awarded accreditation to 24 hospital and primary care organisations. Since the beginning of the Covid-19 pandemic last year, the group has found ways to adapt their accreditation system.

Joel A. Roos MD, Vice-President of International Accreditation, Quality Improvement, and Patient Safety at JCI, explained: “During the height of the Covid pandemic, many JCI surveys, including those in Spain, were transitioned to virtual surveys, versus fully onsite. Additionally, where possible, JCI utilised a hybrid survey approach, whereby part of the surveyor team was onsite at the organisation and part of the survey team was remote.”

He noted: “Feedback from JCI-accredited healthcare organisations about their virtual and hybrid surveys during the pandemic has been extremely positive. Both JCI-accredited healthcare organisations and JCI surveyors reported that offsite and hybrid surveys are, indeed, as thorough and successful onsite surveys.”

Sadly, the Covid-19 pandemic hit Spain hard, causing a high number of cases and deaths. As of 13 August 2021, the country saw over 4.6 million infections and over 82,400 deaths. Following one of Europe’s strictest lockdowns in Spring 2020, Spain reopened to visitors over the Summer, but in November 2020 re-entered a state of emergency that ran until May 2021.

This is now lifted, but some regional restrictions remain. For travellers from certain countries with higher levels of Covid-19 infection, the Spanish government requires a negative Covid-19 PCR test or proof of full vaccination.

Covid-19 has placed private healthcare under huge stress, impacting the private hospital sector enormously.

According to the Spanish Private Health Alliance, ASPE, one in three of the 211,064 patients hospitalised with Covid-19 during 2020 were treated in the private sector. In addition, 29 per cent of the 18,251 people who required intensive care were treated in private hospitals.

According to the Spanish Private Health Alliance, ASPE, one in three of the 211,064 patients hospitalised with Covid-19 during 2020 were treated in the private sector. In addition, 29 per cent of the 18,251 people who required intensive care were treated in private hospitals.

Dr Juan Bosco Rodríguez, Director of Business Development at Vithas Xanit Internacional hospital in Malaga, outlined the situation at his hospital: “There have been three main challenges at Vithas Xanit International Hospital: guaranteeing the safety of patients and professionals against Covid-19, reorganising hospitals and medical centers to respond to the pandemic in areas with the highest incidence of infections; and strengthening the staff and health professionals in order to provide an adequate response to all these needs. All of this whilst maintaining Vithas's quality and safety standards.”

Rodríguez added that new equipment for Covid-19 testing had also been incorporated into the hospitals, including equipment to perform PCR tests wherever necessary, and the acquisition of analysis equipment that detects positive cases in patients with a very low viral load.

“The usual flow of patients has been progressively recovering and, although we have not yet reached normal activity levels, our patients are aware that Vithas hospitals are safe places and understand the risk that postponing certain treatments can pose to their health,” he told ITIJ.

A further challenge for visitors to Spain from the UK, and British expats, is the adjustment to new rules post-Brexit. Travel to Spain has become more complicated under the new European Union-UK Trade and Cooperation Agreement, with the UK now considered a ‘third country’ to the EU – outside the group.

For UK pensioners resident in Spain, entitlement to healthcare is unaffected by Brexit due to provisions in the EU-UK agreement. Similarly, British expats living in Spain before 31 December 2020 also continue to have the right to access the public system, provided they complete an S1 registration form.

Non-residents must obtain the free Global Health Insurance Card (GHIC) from the UK to receive emergency medical treatment. This, as ITIJ’s readers are fully aware, is not an alternative to travel insurance, and visitors are advised to have both in place before travelling. It does not cover all health-related costs, for example, medical repatriation, ongoing medical treatment and non-urgent treatment.

Those who will be in Spain for more than a short visit, but who are not working and are not a Spanish resident, can pay monthly into a special agreement, the ‘Convenio Especial’, which is essentially a fallback way to access public healthcare. The monthly cost is €60 for expats under 65 years old and €157 for those over 65.

However, many advise that expats, and certainly tourists, take out private health insurance to provide security when in Spain.

Regarding the impact of Brexit, Dr Rodríguez of Vithas Xanit International Hospital told ITIJ: “Access to the Spanish public health system is no longer guaranteed now that the UK has withdrawn from the EU, and therefore it is important that travellers who visit us from the UK take out travel insurance that covers all healthcare needs in hospitals and private centers during their stay in our country.”

The easing of Covid-19 restrictions on travel to Spain is good news for the country’s key tourism sector. “The Costa del Sol has a significant volume of residents and international tourists,” said Rodríguez. “For this reason, Vithas Xanit International Hospital cares for a high percentage of international residents.”

He noted that, due to its Costa del Sol location, the Vithas Xanit International Hospital in Benalmádena has ‘a strong commitment to internationalisation’, with 14 languages spoken by healthcare staff, including English, German, French, Dutch, Swedish, Danish, Finnish, Italian, Russian, and Arabic.

Additionally, Rodríguez explained: “It offers a multidisciplinary and multicultural service, taking into account cultural and religious particularities of the international patient. From this department, administrative procedures are also carried out with the insurance companies, repatriations are organised if necessary, and help and support are provided to the families of the patients.”

However, challenges remain in relation to the co-operation between hospitals and assistance companies. “These are mainly (timely) communication and documentation, over- (sometimes under-) treatment, and costs/billing,” said Dr Claudia Mika, CEO of Temos International Healthcare Accreditation.

Mika recommends that healthcare providers establish and maintain specific procedures for international patients. Those procedures should include a range of payment options, cost transparency and the availability of pricelists, clearly defined contact persons on both sides, and the provision of justification documents according to international practices.

Her advice to hospitals was to ensure prompt communication and transparency: “In the interest of domestic and international patients, relatives, payers, and the healthcare provider, the final invoice – together with the complete medical report – should be provided on the day of the patient’s discharge. Following standard criteria can optimise communication and ensure proper handling, continuity of care, and punctual payments.”

With around 5.5 million expats living in the country, and nearly 84 million visitors per year before the pandemic, Spain has stepped up to provide good quality healthcare to all who need it. A strong public service coexists with a number of worldwide leaders in private healthcare, meeting the needs of international patients at a high standard in unison with partners in the global community.