By Irene Palomo and Dr. Osman Sahin
The Spanish healthcare system is relying heavily on the private medical sector to help absorb the shock of the pandemic and address other challenges, such as acute staff shortages and long waiting lists. Last year, private hospitals made up over a third of healthcare activity, performing 41.6% of surgical procedures and treating 33.6% of emergencies.
Private healthcare providers are increasingly playing a pivotal role in supporting the overstretched Spanish public healthcare system, the SNS, as it struggles to meet patient need. But while the private healthcare sector is expanding, existing players and new entrants, must pay attention to the varying, regional nature of treatment demand, and understand the factors behind it, in order to operate effectively.
Spain’s health services are facing huge challenges, including a severe shortage of medical staff and an ageing population, particularly in rural and sparsely-populated areas, such as Asturias, Galicia and Castilla and León. The situation has been exacerbated by a substantial backlog of cases, which worsened particularly during the Covid era. Waiting lists for surgical procedures are most acute in provincial Spain. And across the country, there are big differences in delays for specific specialties.
The country is seeking to address what is essentially a severe supply and demand problem. In order to absorb the shock of the pandemic, the SNS needed to increase capacity dramatically. It was not able to do so itself because of fiscal, technical and regulatory constraints. Supply has simply not increased fast enough, which has opened the way for greater private sector involvement.
Health authorities in the country’s 17 autonomous regions and two autonomous cities (Ceuta and Melilla) – all with different surgical needs and priorities – have sought to work closely with the private sector, often in the form of public-private partnerships, as a means of boosting flagging service levels. About 58% of private hospitals have formal agreements with the SNS. At the same time, concerns about delays in – and the quality of – treatment in the public sector, have prompted many Spaniards especially the young, to purchase private health insurance. Take-up is geographically uneven but largely concentrated in urban areas.
In the wake of the pandemic, private healthcare has consolidated its role as a parallel and complementary system to the SNS. It is now an essential part of SNS’s efforts to reduce waiting lists, accounting for just over a quarter of healthcare spending in the country. More than half of Spanish hospitals are private, mainly based in Andalucía, Cataluña and Madrid, autonomous regions with the greatest demographic and economic weight.
Covid caused a sharp decline in inpatient surgical procedures in 2020, followed by a moderate recovery through 2021–2023, which was uneven across regions and surgical specialties. Overall, surgical procedure volumes are still below 2019 levels. Only urology, plastic surgery and neurosurgery were able to increase in an inpatient setting nationwide. At a regional level, just Murcia, Asturias, and Castilla and Leon have surpassed pre-pandemic inpatient volumes. Large autonomous regions such as Andalucía, Cataluña, Madrid, and the Valencian Community have yet to fully recover.
In December last year, in Spain as a whole there were still nearly 850,000 people on surgical waiting lists. Canarias, Castilla-La Mancha, Cataluña, and Madrid were able to lower average waiting times between 2019 and 2024, while the remaining autonomous regions saw them rise in the same period.
The inability to rebound from the pandemic, especially in large autonomous regions, has been attributed to factors such as doctor shortages (in 2023 the deficit reached nearly 5,900 medical specialists), an ageing workforce, and post-pandemic burnout. Studies conducted last year showed that 24% of doctors in Spain suffered from burnout, and sick leave rates jumping from 6% to 9% in the post-pandemic period. Research has shown that there are heightened regional disparities in not only waiting times, but also capacity and workforce stability.
As a consequence, we’re witnessing a major structural shift in Spain, with a significant volume of surgical procedures – especially dermatology, ophthalmology, and gynecology – transitioning from public hospital inpatient settings to private outpatient facilities. This is most prominent in regions like Andalucía (which has experienced a 700% increase in private outpatient dermatology surgeries since 2019), Aragón and Castilla-La Mancha (which since 2019 saw a 1,000% surge in outpatient gynecological procedures in private facilities). Private sector providers are increasingly vital in absorbing excess demand. They often outpace public facilities in both agility and capacity for certain specialties, likely reflecting Spanish patients’ eagerness to avoid long waiting lists.
Such is the growing reliance on private healthcare that last year the private hospital sector made up about 35% of Spain’s healthcare activity, performing 41.6% of surgical procedures (32.6% in 2023), managing 29.7% of hospital discharges (22.6% in 2023) and treating 33.6% of emergencies (25.2% in 2023). The specialties with the highest number of procedures performed by private practitioners included traumatology (37.1%), angiology and vascular surgery (35.8%), general and digestive surgery (33.1%), and urology and gynecology (30.9%).
In 2024, the turnover of the private hospital sector, which now comprises 431 medical facilities, amounted to EUR 13.9 billion, a third consecutive year of growth, spurring demand for advanced medical technologies and specialized healthcare services. Of the turnover figure for the sector, health insurers and mutual insurance companies, which are largely financing the expansion, contributed EUR 7.92 billion, while public-private collaboration agreements generated EUR 4.655 billion.
Annual investment within the private sector is now close to 1 billion EUR, of which EUR 650 million has been allocated to improvements and innovation and EUR 322 million to Medtech, presenting significant commercial opportunities for companies able to support outpatient care and operational efficiency. All the while, there has been a strong focus on the construction of new private medical facilities, particularly in regions with higher purchasing power, such as Madrid, Cataluña and the Balearic Islands.
While the Spanish healthcare is increasingly dependent on private sector providers, the complexity of demand requires the latter – whether established or new entrants – to focus on specific areas of demand in regions that invest most in private healthcare. There is quite a significant disparity in per capita public spending on healthcare across the country, with the lowest per capita spending regions, such as Madrid, seeing the greatest private sector investment. Other important factors to consider when going to market are that some surgical specialties, as we’ve seen, are more established in some regions than others while waiting lists for all specialisms vary significantly nationwide.
The private sector has been able to support the public healthcare system by being highly agile and responsive to patient needs across the country. Players have had to be alert to demographic and treatment trends to identify gaps in provision and anticipate areas of demand. They have also had to better understand regional health authority challenges and offer appropriate solutions. Such front-footedness and cooperation will be crucial in further cementing the private sector’s role in helping the state meet the country’s healthcare challenges.
About the Authors
Irene Palomo is the Healthcare Analyst for Spain and Italy at FrontierView. Irene supports the Western Europe Healthcare Practice.
Dr. Osman Sahin is the Associate Practice Leader for Healthcare Strategic Insights at FrontierView. Osman leads the Western Europe Healthcare Practice.
