In February 2023, hundreds of thousands of people gathered on the streets of Madrid, Spain’s capital city, to voice their outrage at the deterioration of public healthcare in the region. According to the protestors, Madrid’s right-wing government has paved the way for the privatization of the healthcare system, obstructing citizens’ access to care and emburdening health workers with a lack of resources and staff. The situation has led to demonstrations by citizens and strikes by health workers.
The first step in remedying the decline of public healthcare in Madrid and across Spain is “to support those on strike, those who are in need for getting their job done,” said Manuel Franco, an epidemiologist and spokesperson for the Spanish association of public health and healthcare administration.
The prospect of recovering Spain’s public healthcare system rests on the conviction that cries for change bear tangible power in a democratic state.
According to Franco, the gradual privatization of the Spanish healthcare system can be traced back to the global financial crisis of 2008. In the early 2000s, Spain had one of the “most comprehensive health care systems” in Europe, said Franco. The success of the system was largely due to its emphasis on primary care, which is the most basic, essential level of healthcare and a patient’s first point of contact with a doctor. Franco noted that 80% of the exchanges between a population and its national healthcare system are through primary care.
The 2008 crisis incurred tremendous debt upon Spain’s public sector. To mitigate the impact of the crisis across Europe, the European Union (EU) imposed a series of austerity measures—rigid economic policies that aim to reduce debt in a country’s public sector—on its member states. These EU policies, coupled with the measures introduced by Spain’s own government, led Spain to cut down on its social services spending, especially in the realms of education and healthcare, said Franco.
Javier Olóriz, an otolaryngologist based in Granada with experience in both the public and private sectors of the Spanish healthcare system, said in an email to The Politic that patients seeking treatment in Spain today “find themselves with a saturated system that generates discontent in the population.” According to Olóriz, “this discontent is often transferred to the health professional who, in general, has lost the social status he had before, so the doctor-patient relationship is different from the one that existed.”
Years after the first cuts were made to the public sector, the COVID-19 pandemic exacerbated the decline of primary healthcare in Spain. According to Franco, in the first stages of the pandemic, the Spanish government failed to implement large-scale measures regarding quarantine and vaccination. Instead, the burden of caring for sick patients fell on the primary healthcare system, leaving doctors and nurses overworked and overwhelmed.
Ángela Hernández Puente, a surgeon and the Secretary General of the Association of Physicians and Higher Graduates (AMYTS), a major medical union Madrid, stated that the gradual decentralization of public health services in Spain has further contributed to the healthcare system’s troubles.
“The management of practically all of the Spanish healthcare system was transferred to the 17 autonomies [the 17 autonomous communities into which Spain is divided], which in theory are organized by the Interterritorial Council at the level of the Ministry of Health System, but its decisions are not binding,” Hernández Puente said in an email to The Politic. “Only the autonomous cities of Ceuta and Melilla remain under the Ministry of Health,” she noted.
According to Hernández Puente, this transfer of control has subjected the healthcare system to political disputes. “What we miss the most is medium and long-term planning without partisan or electoral interests,” Hernández Puente said, calling the interference of partisan interests in the healthcare system “a perverse phenomenon.”
Due to a range of factors—the 2008 financial crisis, the COVID-19 pandemic, and the decentralization of control over public health services—the Spanish healthcare system has become increasingly vulnerable to privatization. Although Olóriz pointed out that referring patients to the private sector may be “cost-effective for the system and therefore free up resources for other needs,” this privatization carries troubling implications for Spanish citizens. It exemplifies, in the words of Franco, an “absolute for-profit movement” by health insurance companies and the global investors that fund them.
According to Franco, right-wing authorities across the country are “moving towards the privatization of the healthcare system in general, not only the primary healthcare system.” Beyond Madrid, a similar shift has taken place in Catalonia and Valencia. Valencia, however, successfully reversed the privatization process after one of its elections. The gradual erosion of public healthcare has provoked strikes by health workers and protests by citizens, most recently on the streets of Madrid.
Hernández Puente identified several more recent catalysts for the strikes and protests in Madrid. In September 2020, the regional administration refused to comply with a series of improvements aiming to support doctors and pediatricians working in primary healthcare. This refusal instigated a major strike by health workers as well as the city-wide protests in both November 2022 and February 2023.
Furthermore, in the summer of 2022, the administration dismantled out-of-hospital emergency services, which are crucial in offering treatment to patients in rural areas. This decision resulted in the “extra-hospital” strike by health workers.
The strikes and protests have already achieved concrete results. According to Hernández Puente, before the extra-hospital strike, 14 out of 37 out-of-hospital emergency centers lacked complete medical teams, including a doctor. By the end of the strike, all 37 centers had doctors and restored adequate working conditions for professionals, Hernández Puente said. She also noted that the primary healthcare strike has led to agreements with the Madrid administration, which will “represent, if fulfilled, a step [away from] the deterioration that the base of the public health system in the Community of Madrid has been suffering.”
Despite these heartening outcomes, the pursuit of improved healthcare in Spain is far from over. Hernández Puente said that the extra-hospital strike is still ongoing, the next date being April 19th. In the face of this continued struggle, implementing enduring reforms and uplifting those on strike remains vitally necessary.
Hernández Puente argued that due to the decentralization of public health services, “a state and regional agreement between the major parties would be necessary to establish the basic lines of management of the different regional systems and establish binding coordination at the state level in the medium and long term.”
Furthermore, Olóriz stated that “increasing staff and creating more public hospitals could be considered as a solution [but would] undoubtedly be much more expensive for the administration than referring patients to private hospitals.” He noted that the administration could allocate more resources to public health, though this would require citizens “to demand from their politicians that their taxes be dedicated to health and not to other activities.”
According to Franco, seeking “measures that will cover and protect the health of the people” is the long-term solution to the healthcare system’s challenges. “To me it’s very clear that investing, innovating, and putting the effort in primary healthcare is not only necessary, but is the only way to go to the future.”
Ultimately, amplifying the demands of health workers and citizens is crucial to alleviating the healthcare system’s troubles.
“It is essential to listen to and rely on professionals, specifically doctors and physicians, in the future of the Spanish healthcare system,” said Hernández Puente.
As the quest to revive public healthcare in Spain continues, the hope that civic voices will inspire change endures.