Stories From the Field:


From Aslyums to the Recovery Model: Examining Public Mental Health Delivery in Spain

Dr. Alex Sidelnik, a third year resident in the MGH McLean Adult Psychiatry Residency Training Program, was granted a Center for Global Health Travel Award to study mental health services in Spain. 

During the month of June 2015, I traveled to Madrid, Spain to participate in a global mental health elective with the assistance of the MGH Center for Global Health. As my interests involve health systems and models for delivering mental health care, I arranged a four week stay within the public mental health system. Spain has both a public and private healthcare system, though during my time I spent time only in the public system. Spain has a long history of providing public healthcare which was formally sanctioned in the Spanish Constitution of 1978 establishing the right to health protection and health for all citizens. Over past several decades, there have been several legislative actions to provide regulation, structure of care, and actions to improve quality and safety resulting in a comprehensive National Health System.

The system is largely decentralized and is compromised of three general divisions including the central government, autonomous regions, and local councils, each with their own responsibilities in caring for Spain’s population of roughly 46 million people.  The Central Government has multiple responsibilities which largely involve coordination of care among different autonomous communities, developing national policy on medications, assistance in foreign medical affairs, and developing national standards for health centers and services. The 17 autonomous communities have the responsibility of providing healthcare to their residents. Each autonomous community has its own Health Service with an administrative and management body responsible for all health care centers and services in the region. The third division of local councils is responsible for cooperation in the management of public services between central and autonomous health administrations designed to promote cohesion in the National Health System. The health services in each community are structured on a two tier system with both primary care and specialists. Health care centers are staffed by multidisciplinary team of general practitioners, nurses, pediatricians, social workers, and case managers. They also assist in health promotion and disease prevention. Specialist care is provided in specialist health centers and hospitals. Health services within each autonomous community are divided further into health areas and zones according to demographic and geographic criteria.

The healthcare system enjoys public support with approximately 73.1% of people in 2011 having a positive assessment of the system reporting it functions well but needs some changes and 21.9% of people reporting parts of the system function well, but overall it needs fundamental changes. The overall cost of healthcare is also substantially lower than in the United states with the per capita cost of public healthcare approximately 1,622 euros in 2010 representing 9.6% of GDP which compares to 17.1% of GDP in the United States. Life expectancy, although not a specific measure of the quality of healthcare, is 82 years in Spain which compares to 80 in the European Union and 79 in the United States.

During my time in Madrid, I spent one week in different levels of care within the public mental health system in a health service area of the Autonomous Community of Madrid including a day hospital, ambulatory mental health center, inpatient psychiatric unit, emergency department, inpatient psychiatric consultation service, and long-term psychiatric rehabilitation unit. The health service area, Legánes, is a community south of Madrid which is home to one of the first psychiatric hospital in Spain, the Instituto Psiquiátrico Servicio de Salud Mental José Germain with origins dating back to 1851. The Institute was also the first hospital in Spain to fully transition its asylum model for a recovery model in managing chronic mental illness. The health service area has a strong focus on health education, community psychiatric care, and the recovery model through a single-payer system. There are many similarities and differences in mental health care between the United States and Spain which are too numerous to describe in this here. However, differences in both health systems may largely reflect structural differences in health care financing, health system integration, availability of mental health resources, and approach in managing chronic diseases.  The experience overall was extremely valuable and has changed my view on how mental health care can be best delivered.

I am grateful to the MGH Center for Global Health for supporting this trip and work.