The objective of any health system is to respond to the needs of the population. In order to do so, we must start by knowing the demographic characteristics, main health problems and socio-environmental conditions. 

Healthcare spending in Spain has been characterized in these two decades of the new century by an increase in spending, producing an imbalance between the need for spending and the capacity to finance it. This fact leads us to rethink how this expenditure is financed, how it is distributed by sector and which chapters absorb the largest portion of health expenditure.

In view of this concept, we will see that the fundamental predominance of health spending falls on hospital and specialized services, followed by non-hospital pharmacy spending. The third place is occupied by primary care services.

Healthcare in Spain was constituted as a contributory service provision. Initially, it was provided by workers who generated contributions, pensioners and their beneficiaries. Later, with the reform of the LGS in 1986, the system was transformed in such a way that it was redirected towards: the universalisation of health care, the financing of expenditure through taxes and the decentralisation of the provision through the transfer of competences to the different autonomous communities. In this path of development of the SNS we must pay attention to what the texts of 3 laws show us. The Organic Law 4/2000, on the right and freedom of foreign residents in Spain, the Law 16/2003, on the cohesion and quality of the NHS, which recognizes the holders of health care and the Law 33/2011, General of Public Health.

As a constitutional right, the protection of health has different restrictions, adjusting to those included in the catalogue of benefits and in the service portfolio, based on the criteria of efficiency and equity.

The demographic evolution

The changes that are taking place in the population have caused the hitherto accepted principles of financial regulation of the NHS to be questioned because they need to be rethought. The size and structure of the population, in which we find an increasingly large population, accompanied by an alarming ageing.  The population over 65 years of age is increasing year by year, accompanied by a decrease in the birth rate, depopulation of rural areas and migratory movements towards the coastal areas of the Mediterranean basin.

The ageing of the population is not only a problem for the economy, through the reduction of the labour force. It directly leads to deficiencies in funding and sustainability. And these are costs that will continue to increase in the coming years.

That is why the organisation of health needs to be redirected towards preventive activities and health education, even if the results are in the medium to long term and there is no political return in the short term. It is also a priority to turn towards social and health activities, making room for actions on dependency and chronicity.

It is certain that the necessary change in these policies will produce resistance in both the political and social spheres. The traditional hospital-centric custom produces the belief in the population that all problems will be solved in the hospital environment, including the care of chronic and dependent people.

This custom and need to rethink health financing leads us to conclude by asking the question: What do we want as a society? And how are we going to finance it?

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