SINOUÉ

The Spanish public health insurance system is called Insalud (Instituto Nacional de Gestion Sanitaria). It is based on compulsory contributions from Spanish employees. 
 
Spanish Social Security doctors are salaried employees, employed by the Instituto Nacional de Gestion Sanitaria. The patient, therefore, does not pay the doctor directly, thus ensuring transparent and homogeneous pricing. 
 
The Spanish Social Security assigns and taxes treating doctors to patients, based mainly on geographical proximity. 
 
It is the attending physicians who redirect their patients to specialists. They are therefore the main relays to mental health establishments and specialists in Spain.

Contributions to the Insalud system are mandatory for employees. However, they can decide to contribute to a mutual insurance company in addition. The latter generally has its own network of hospitals, clinics and laboratories, which generally allows faster access to care. These mutual insurance companies also make it possible to obtain reimbursement or coverage for care not reimbursed by Insalud (dental and optical expenses). 
 
In Spain, private insurances allow patients to be reimbursed for procedures and care requested from any doctor or establishment (according to the terms of the insurance contract). 

The regionalisation of the Spanish health system and health care provision has led to significant disparities in the service provided to the population.
As in other European countries, waiting lists for specialists, special treatments and non-emergency operations have grown longer, creating a wide opportunity for private health insurers and private health offers that complement the public health care offer. 
The recent austerity policy has led to multiple budget cuts and job cuts in public hospitals and clinics, giving a sense of significant deterioration in the public health service.  
Delays in access to health care are tending to lengthen and emergency departments are increasingly saturated.  Beds are increasingly over-occupied in public institutions, which are also seeing their care staff reduced for lack of resources. 
The gradual deterioration of the public health system in Spain suggests problems similar to those encountered in France: a public health system based on employee contributions, unbalanced by the increase in life expectancy, and subject to economic and budgetary challenges. Faced with this precariousness of public health care, private actors represent a complementary offer that is now essential to ensure a quality health offer throughout the country.