Why the public health system in Spain’s capital is on the brink

Madrid's regional system of primary public healthcare is struggling to cope with high numbers of patients, many of whom are unable to access treatment elsewhere, with some observers warning it could collapse.

Why the public health system in Spain's capital is on the brink
Demonstrators march during a demonstration called by citizens under the slogan "Madrid stands up for its public health. Against the destruction of primary health care" in Madrid on November 13, 2022. (Photo by OSCAR DEL POZO / AFP)

Enrique Villalobos’ father is just one example of how the system is deteriorating.

“It took nine months for my 85-year-old father to have his prostate operation and he ended up in the emergency department several times because he was at death’s door,” says Villalobos.

Hundreds of thousands of protesters took the streets of the Spanish capital last Sunday to demand action to save its healthcare system.

READ ALSO: Thousands rally in defence of Madrid public healthcare

Among the demonstrators, who included healthcare workers, unions and politicians, were several famous faces, including Oscar-winning director Pedro Almodovar who wore a white T-shirt with a green heart saying “public

“This is not a political demonstration, it affects all of us and mostly the most vulnerable,” he said.

“Public healthcare is a fundamental right we have which is written into the constitution.”

Public healthcare in Spain, which is highly decentralised, is managed by regional governments. 

In Madrid, the richest and most densely populated region with nearly seven million people, annual spending per resident is just 1,491 euros ($1,545) — the second lowest of Spain’s 17 regions, according to a 2020 health ministry

“People have become more and more aware of the progressive deterioration of public healthcare,” says Villalobos, head of FRAVM, a group that was one of the driving forces behind Sunday’s protest.

The authorities said 200,000 people joined the rally but organisers gave a figure three-times higher, saying it had drawn 670,000 protesters who could be seen thronging the wide boulevards running past city hall.

‘There’s nowhere else’

Local healthcare centres are understaffed, their doctors overwhelmed with scores of patients and never-ending waiting lists, as key screening appointments such as mammograms are cancelled or rescheduled for months in the
future, Villalobos says.

To address the problems, the regional government is trying to promote video consultations.

“How can you diagnose something like peritonitis by video conference?” asked the 53-year-old, accusing the regional authorities of trying to push for “an American-style healthcare model in Madrid”.

But such allegations are rejected by the region’s right-wing leader Isabel Diaz Ayuso, who dismissed Sunday’s protest as politically motivated.

Her recent decision to reopen 80 walk-in centres for non-hospital emergencies — closed at the start of the pandemic — but with staffing levels at half what they were previously sparked criticism.

Exhausted by the Covid crisis, emergency centre doctors began an open-ended strike on November 7.

Although they reached a deal to end their strike late on Thursday, some 4,240 primary care doctors and 720 paediatricians are due to go on strike on Monday.

Ivan Saez, a 48-year-old teacher, says he can no longer rely on seeing his family doctor at the local health centre — and has no idea who will treat him.

“It could be someone who is seeing 50 other patients and who calls you when they have a free moment. But it won’t be the doctor you’ve had for years who knows your medical history,” says Saez who was at Sunday’s protest.

“If something happens one day, I’ll have to do what everyone does and go to hospital even if it’s a small thing, not because it’s urgent but because there’s nowhere else.”


As a primary care doctor, a normal day can “start with 40 appointments on the books” but “you can end up seeing 60 or 70 patients,” says 62-year-old Isabel Vaquez Burgos, who worked in a busy clinic until becoming a
representative for the Amyts doctors’ union.

Jose Manuel Zapatero, 65, worked as a family doctor for 40 years but has just retired, exhausted by the extra five or six hours he put in every day just so he could see an average of 60 patients.

If it was not for the exhausting conditions, Zapatero says he “would have carried on working”.

And the situation was putting an impossible strain on them, with doctors “becoming depressed, having anxiety attacks and getting sick”, he says.

“It’s called burnout.”

Others have simply quit, moving abroad or to other regions of Spain where there is more spending on healthcare, further worsening the outlook.

READ ALSO: Why Spain is running out of doctors

Member comments

Log in here to leave a comment.
Become a Member to leave a comment.
For members


What are the rules on IVF in Spain?

Spain has some of the best fertility clinics in Europe and people travel from all over for assisted reproduction techniques here, both because of the high success rates and standard of care, but what are the invitro fertilisation rules in Spain?

What are the rules on IVF in Spain?

Spain has the second lowest fertility rate in the EU, with an average of 1.23 children per woman, according to the latest data provided by the European Statistical Office, Eurostat, corresponding to 2019 and updated at the end of June 2021.

A report by the Spanish Fertility Society (SEF), says that more and more couples are having problems conceiving and many are choosing to undergo assisted reproductive techniques in order to become parents.  

They consider infertility as: “the inability to achieve pregnancy after one year of sexual intercourse with normal frequency and without the use of any method of conception”.

Although male infertility factors are responsible for between 25 percent to 35 percent of cases, the number of older women who want to have children in Spain is the number one issue, the society explains.

But, it’s not just Spaniards who use fertility clinics in Spain, people come from all over Europe and even further afield. A recent study by the American Society for Reproductive Medicine found that five percent of European fertility care involves patients cross border travel and that the most popular European destinations are Spain, the Czech Republic, Denmark and Belgium.

In 2019, Spanish fertility clinics carried out 18,457 treatment cycles for foreigners, the majority from France and Italy. According to Barcelona IVF, the French, English and Italian are the ones who travel the most to Spain to undergo fertility treatments.

So what are the rules on IVF and other assisted reproductive techniques in Spain? 

The In Vitro Fertilisation Law in Spain states that any woman over 18 years old can undergo reproductive techniques in Spain regardless of marital status and sexual orientation. Egg freezing for future use is also allowed.

This legal framework establishes that assisted reproductive techniques can only be used when there are possibilities of success and when they do not pose a serious risk to the health of the patient.

The IVF law in Spain does not allow for uterus transplants or the use of surrogates or gestational carriers.  

While the law has not yet incorporated any mention of ROPA techniques, this is also offered in Spain. The ROPA method is used when women in a same-sex relationship want to share parenthood, whereby one provides the egg and the other one carries the baby.

What is the law on PGD and PGS testing?

Preimplantation Genetic Diagnosis or PGD is when the embryos are tested for specific inherited genetic issues such as cystic fibrosis. PGS also referred to as PGT-A is Preimplantation Genetic Screening or Testing and tests to see whether the embryo is genetically normal. The second one is typically used for women over the age of 35 or for those who have had multiple implantation failures or miscarriages.

Both types of tests are legal in Spain, however, the IVF law prohibits these tests to allow for selecting the sex of the baby or for physical characteristics. In some countries, such as the US for example, it’s very common to find out the sex of the embryo when these tests are carried out.

What are the rules for IVF in public health care?

Assisted reproduction techniques such as IVF and artificial semination are available through the public health care system in Spain, however, out of the more than 400 fertility centres in Spain only between 10 and 20 percent are public centres.

READ ALSO: Spain restores free IVF to singles, lesbians and now trans people

This means that there are also long waitlists for reproductive techniques through the public system, as well as stricter rules. According to the latest data available, wait lists for IVF are just over one year, however, in many regions, this can go up to two years or longer. In fact, waiting much longer than this is not uncommon.

The government laws establish that the maximum age to undergo these treatments in the public health system is 40 years in the case of women and 55 years for men. This age limit drops to 38 in the case of insemination with a partner’s semen.

The state guarantees a maximum of three rounds of IVF, six if it is by artificial insemination with donor sperm and four if it is with a partner’s sperm. 

Some regions in Spain, have their own rules however such as Madrid which raised the age to 45 and increased the number of rounds from two to four. 

READ ALSO: Madrid raises age limit for women to have free IVF up to 45

What are the laws on egg and sperm donations?

The In Vitro Fertilisation Law in Spain also regulates egg and sperm donation. Egg and sperm donation in Spain is anonymous, voluntary and altruistic.  

The choice of the donor will only be made by a medical team and cannot be selected by the patients, however, doctors will try to match certain physical characteristics. 

Is embryo donation/ embryo adoption legal in Spain?

Yes, according to Article 11 of the law 14/2006 embryo donation or embryo adoption as it is commonly referred to is legal in Spain. Donations must be anonymous and altruistic. 

A couple may wish to donate their embryos if they have a surplus and have already completed their family, while a couple or single woman may want to adopt an embryo if there have issues with their eggs or sperm.

What are the costs of IVF in Spain? 

IVF is a costly process when you go privately, but prices in Spain can be almost half of those you would pay in the US for example. According to the IVF Abroad Patient’s Guide 2022 for IVF using your own eggs, the costs range from €3,600 to €6,700. 

If using an egg donor, it can range from €5,900 to €8,500. For IVF using embryo donation, the costs range from €3,000 to €5,000 and for IVF involving egg freezing, the costs range from €3,500 to €4,700.

Medications for the injections are typically not included in these prices and can cost an extra €1,000 on top.