Public and private

🏥 Public and private

Healthcare and education are public and free, but a growing share is delivered through private companies and schools paid for with public money, and another share is paid by families out of their own pocket. This page measures, region by region, how much there is of each: healthcare contracts, public hospitals run by companies, private insurance, state-funded private schools, vocational training and private universities. Figures are per inhabitant or in percentages, and euros are adjusted for inflation.

Private schools: state-funded (concertados, financed with public money) and fully private. Private insurance is the answer given by respondents to the Health Barometer, which counts both individual and employer-provided insurance.

Healthcare

How much public healthcare pays private providers

Every region refers patients to private clinics for tests, operations or specific specialties: these are the healthcare contracts (conciertos). In 2024 the regions as a whole spent 8.7 % of their healthcare budget on them. Catalonia (21.6 %) and Madrid (12.2 %) spend the most. The line marks 15 %, the threshold that Rafael Bengoa, former Basque health minister and former WHO director, sets as the most that European systems usually want to contract out.

In euros per inhabitant and adjusted for inflation, Madrid has gone from 67 € in 2002 to 224 € in 2024; the regions as a whole, from 144 € to 176 €. Madrid's jump coincides with the opening of the concession hospitals of Torrejón (2011), Rey Juan Carlos (2012) and Villalba (2014), which the statistics do count as contracts.

Public Healthcare Expenditure Statistics (Ministry of Health), consolidated spending of the autonomous regions. Contracts: care bought from outside providers (hospital, specialist and primary care, patient transport) and from other administrations. The last two years are provisional. Catalonia: its high share comes from the historical network of non-profit contracted hospitals (foundations, religious orders, SISCAT consortia), not from for-profit companies. Valencian Community: the statistics do not record the per-inhabitant payments to the concession hospitals of the Alzira model as contracts; the 4.0 % of 2024 does not mean little privatisation (see «How these data have been read»).

Privatising coverage: hospitals paid per inhabitant

Beyond the contracts, Madrid and the Valencian Community are the only regions that have handed companies the complete care of entire areas: the administration pays the concession holder a fixed amount for each assigned inhabitant and the company becomes responsible for their health. José Manuel Freire, professor emeritus at the National School of Public Health, calls this privatising coverage. In the Valencian Community it came to cover 18.1 % of the population; after the reversals that began in 2018, 2.9 % remains (only Vinalopó, in Elche). In Madrid it reaches 15.4 % (1,096,135 people in 2025, 622,396 of them in per-inhabitant concessions and the rest at the Fundación Jiménez Díaz, which is paid per procedure).

Assigned population: the most recent figure published by each hospital or regional health department (SERMAS annual reports, DOGV reversal decrees); in years without an official figure it is estimated by keeping each hospital's share of its region, so the series is approximate. In addition, 24.2 % of Madrid residents have as their hospital one of those built since 2008 by companies that collect a fee for 30 years and run the non-clinical services (cleaning, catering, maintenance); their clinical staff are public and they are not counted in the chart. The National Hospital Catalogue classifies concession hospitals as public.

Madrid: the waiting list that is not published

Every month the Community of Madrid publishes how many patients are waiting for a first consultation, a test or an operation. That figure only counts those who already have a date: if the department's schedule is closed, the patient is left pending an appointment and does not appear. The SERMAS annual report does count them. On 31 December 2025 the full list stood at 1,324,689 patients, 186 per 1,000 inhabitants, and 366,603 of them had no appointment.

Those without an appointment are not included in the average waiting time either. If the waiting time each region reports is compared with the one that would correspond to the size of its list (a line fitted with the other regions), Madrid has diverged from the rest since 2023: in its latest cut-off it reports 68 days for a first consultation when its list would imply a wait of about 162, a gap of 3.2 standard deviations.

SERMAS annual report (waiting-list chapter: 2015-2020 from the PDF of the full report, from 2021 from its open data files) and monthly reports of the Regional Health Department. Tests: the 8 procedures detailed in the report. Until 2022 the report's total was considerably lower than the one published in the December monthly report (in 2022, 394,347 versus 555,026); since 2023 the patients with an appointment in the report match the monthly report, so the 2023 jump partly reflects that change of criterion and the series should not be read as continuous. Expected wait: for each half-yearly cut-off of SISLE-SNS (Ministry of Health) a line is fitted between the rate of patients per 1,000 inhabitants and the average wait of the other regions. Madrid's list is larger than any other, so its expected wait is an extrapolation of that line.

Unable to get an appointment at their own hospital, many patients end up at another through free choice, introduced in 2009. The balance (appointments received minus those transferred out) of privately run hospitals went from 33,590 appointments in 2014 to 225,575 in 2024; publicly run hospitals lose almost as many.

Free-choice balance from the SERMAS annual report and the «Consultas Libre Elección» sheets of each hospital's annual report. Privately run: concession hospitals (Rey Juan Carlos, Infanta Elena, Villalba, Torrejón) and Fundación Jiménez Díaz. The Regional Health Department does not publish the algorithm that offers alternative hospitals when booking an appointment, nor what each hospital bills for these patients.

Those who can afford it pay for insurance

Professor Rosa María Urbanos, the first director of the National Health System Observatory, points to two reasons for taking out private insurance: shorter waits and being able to see a specialist without going through the family doctor. According to the Health Barometer, the population with private insurance has gone from 17.2 % in 2018 to 32.6 % in 2024; in Madrid, 44.6 %.

Health Barometer (table 1 of the Ministry of Health report «Evaluación de la sanidad privada en el sistema sanitario de España», December 2025), individual or employer insurance. Household spending: INE Household Budget Survey, Health group (medicines, dentist, optician, consultations and hospital care paid directly); it does not include insurance premiums.

Private hospitals within the public network

Many privately owned hospitals work almost exclusively for public healthcare: they are part of its network or replace it under contract. According to the Ministry of Health report of December 2025, between 2011 and 2023 their spending grew by 84.6 %, compared with 50.3 % for public hospitals.

National Hospital Catalogue (Ministry of Health): privately owned, mutual or non-profit hospitals that belong to the public-use network or have a substitute contract. It does not include concession hospitals, which the catalogue counts as public.

Education

State-funded and private schools

In the 2024-2025 school year, 33.2 % of pupils from pre-primary to vocational training in Spain attended a private school, most of them state-funded. Madrid (46.4 %) is the region with the most pupils in fully private schools: 18.6 %, compared with 8.7 % in Spain.

Non-University Education Statistics (Ministry of Education). In the Basque Country and Navarre state-funded private schools have a historical origin (ikastolas, cooperatives) and their share is falling over time; in Madrid fully private schooling is growing. In the first cycle of pre-primary (ages 0-2), «state-funded» includes any private centre receiving some subsidy.

How much the regions pay state-funded private schools

In 2024 the education authorities spent 176 € per inhabitant on contracts and subsidies to private schools (2025 euros), 13.2 % of their spending. In Madrid the figure has gone from 120 € in 2000 to 196 €, and its share is now 17.9 %.

Public Expenditure on Education Statistics (Ministry of Education), outturn spending. The item also includes subsidies to fully private schools and, since 2017, transfers to private universities.

Vocational training: private provision grows where public provision is lacking

Between 2011-2012 and 2024-2025, students of higher-level distance vocational training in private centres went from 1,582 to 97,565: they now account for 59.2 % of all higher-level distance vocational training. In fields such as Health, most higher-level students study in private centres.

Fields with at least 5,000 higher-level students in Spain. Private: state-funded and fully private. Distance students are counted in the region where the centre has its headquarters, which is why a few regions concentrate online vocational training.

Private universities

In the 2024-2025 academic year, 18.7 % of on-campus bachelor's students attended a private university in Spain, and 32.8 % in Madrid. At master's level, counting distance learning, private universities are already the majority: 55.2 % in 2025-2026, compared with 20.2 % in 2010-11. There are 45 active private universities, 13 more than in 2015-2016.

University Student Statistics (Ministry of Science, Innovation and Universities). Students are counted in the region of the university; distance universities (UNIR, VIU, UOC, UDIMA...) are concentrated in a few regions, which is why the ranking uses on-campus teaching. The last academic year is provisional.

The spending that does not appear in the budget

A budget says how much a government plans to spend; the general account, how much it actually spent. In Madrid the difference is concentrated in what is paid to private hospitals. In 2024 SERMAS budgeted 803 million for the Fundación Jiménez Díaz and the four concession hospitals, and ended up paying 1,756. Overall, SERMAS spent 33.8 % more than budgeted. The item for late-payment interest, paid when invoices and settlements are paid late, had 5.0 million and ended at 45.6.

Which companies get the money

The general account's breakdown by hospital lets us name who gets paid. In 2024 SERMAS paid 1,611 million euros to Quirónsalud for the Fundación Jiménez Díaz and its three concession hospitals (236 € per Madrid resident), 78 % of everything it paid to private healthcare companies; in 2016 it was 495 million.

General Account of the Community of Madrid: spending executed (recognised obligations) under each privately managed hospital's sub-item, assigned to the company that controlled it that year (Torrejón: Sanitas and Asisa until 2018, Ribera Salud from December 2018). Each year includes settlements from previous years paid in it, hence the jumps. "Other companies": the remaining contracts with private providers (dialysis, ambulances, tests, laboratories...), whose company is not shown in the account. Excludes the fee for hospitals built under works concessions.

The missing money is covered during the year through budget amendments. In 2024 SERMAS received 3,120 million in credit transfers. That year, the items of the Administration of the Community budgeted without a specific purpose, «unforeseen expenses and shortfalls» and the contingency fund, gave up 2,597 million.

When a service is provided without a contract in force or without prior audit, the payment has to be legalised afterwards through a validation by the Governing Council. The Chamber of Accounts warns that its overuse weakens oversight. The summaries of the agreements record 586 validations in 2021 and 92 in 2025; between 2019 and 2025, those for Health totalled 819 for 2,062 million (2025 euros).

General Account of the Community of Madrid (General Comptroller): outturn of each entity's expenditure budget by sub-item (2016 onwards; 2015 is not published in PDF) and note on budget amendments. Credit transfers add up to zero across the Community as a whole: what one item receives, another gives up. Catalonia: monthly execution of the Generalitat budget (open data). Validations: official summaries of the Governing Council agreements since 2004, with the amount cited in each agreement; they are a summary and fall somewhat short (189 in 2024, compared with the 209 counted by the Chamber of Accounts in its report on the General Account). The Madrid Social Care Agency and the Social Housing Agency do not publish their note on budget amendments.

Minor contracts (up to 15,000 euros excluding VAT for services and supplies) are awarded without a tender. Buying the same thing from the same supplier through several minor contracts within the same year can be a way of avoiding a tender. The Community of Madrid only allows its own to be downloaded after a captcha, so the table uses the open data of the health services of Andalusia and Catalonia: the percentage of the amount that falls in groups from the same body, same supplier and similar subject that exceed the threshold.

Procurement Platform of the Junta de Andalucía (health bodies; the Andalusian Health Service is split by province) and Public Procurement Services Platform of Catalonia (Departament de Salut and ICS, with detail since 2023). Similar subject: same first words of the title in Andalusia and same three-digit CPV code in Catalonia; threshold of 15,000 euros (40,000 for works) excluding VAT, under the 2017 Public Sector Contracts Act. It is a signal to review, not proof of contract splitting: a body that buys for many hospitals (SAS, ICS) accumulates legitimate purchases from the same supplier. Official reports: Madrid Chamber of Accounts on minor contracts and on the 2024 General Account.

How these data have been read

Administrations publish summary figures that often leave out what matters. This page has followed a method to avoid staying on the surface, using official documents in every case:

• Go to the full document. The healthcare spending statistics give a percentage for contracts; their tables by region and item show that in the Valencian Community the payments to the concessions are not there: its purchases of goods and services weigh about 10 points more than the average of the rest, roughly what the concessions cost, and in 2018, when La Ribera returned to public management, staff spending jumped suddenly without that item falling. It is an indication that only the Conselleria's outturn budget or a report by the Sindicatura de Comptes could confirm.
• Read the definition of each indicator. The National Hospital Catalogue calls concession hospitals public; the education item for contracts includes subsidies to fully private schools; distance vocational training and universities are counted where their headquarters are.
• Compare against a base year, in constant euros and per inhabitant, to separate real growth from growth that only reflects prices and population.
• Break down the figures. The vocational training total hides fields such as Health, where private provision is the majority; the university total hides master's degrees.
• Compare the publicity report with the accountability report. Madrid's monthly waiting-list report only counts those with an appointment; the SERMAS annual report also counts those waiting without one.
• Check against the other regions. If a region's average wait does not match the size of its waiting list, something is being left out of the calculation.
• Budget versus general account. Items that are knowingly under-budgeted are topped up during the year through budget amendments, and the general account says where the money comes from.
• Follow the flows, not just the totals. The free-choice balance shows which hospitals gain patients and which lose them; validations and repeated minor contracts point to spending made outside the ordinary procedure.

Sources and notes

• Ministry of Health – Public Healthcare Expenditure Statistics (satellite accounts, economic and functional classification by region).
• Ministry of Health – National Hospital Catalogue.
• Ministry of Health – Evaluación de la sanidad privada en el sistema sanitario de España (December 2025), with the Health Barometer.
• Privately run hospitals: table compiled for SpainFacts from the DOGV reversal decrees, the SERMAS hospital annual reports and, where there is no official figure, press reports with attribution; each row carries its source in the downloadable table.
• Community of Madrid – Annual reports of the Madrid Health Service (waiting list on 31 December and free choice, also in each hospital's annual report) and monthly waiting-list reports; SISLE-SNS (Ministry of Health) for comparison with the other regions.
• Community of Madrid – General Account (General Comptroller: budget outturn and budget amendments by entity), summaries of the Governing Council agreements and Generalitat de Catalunya – budget execution.
• Minor contracts: Junta de Andalucía – minor contracts and Generalitat de Catalunya – Plataforma de serveis de contractació pública.
• INE – Household Budget Survey (health spending per person).
• Ministry of Education – EDUCAbase: Non-University Education Statistics and Public Expenditure on Education Statistics.
• Ministry of Science, Innovation and Universities – University Student Statistics and Register of Universities, Centres and Degrees.
• Context: elDiario.es reports «De pacientes a clientes» (14-02-2026) and «El Gobierno trata de levantar un muro contra la privatización desaforada en sanidad y educación» (13-02-2026); the statements by Freire, Bengoa and Urbanos come from the former. None of the figures on this page come from them.
• Deflator: INE annual average CPI. Population: INE.

Data updated 7 minutes ago