Madrid remains Spain's leading region for healthcare privatisation. Asturias, Extremadura and Castilla-La Mancha are catching up fastest, while private cover and out-of-pocket costs deepen differences in access.
Private healthcare spending in Spain is estimated at around 34 billion euros in 2025. That equals 2.5% of GDP and about 27% of all healthcare spending, according to figures from the Federation of Associations for the Defence of Public Health. The total includes insurance payments, regional contracts and direct household spending.
The shift reaches every autonomous community. It is no longer a small part of the system.
Madrid remains the region where private healthcare has the strongest hold. The federation's 12th report places Catalonia and the Balearic Islands next, with the Canary Islands also near the top. FADSP gives Madrid the maximum score of 34 points. Catalonia and the Balearic Islands receive 28 each, while the Canary Islands score 26.
In the FADSP summary, Madrid receives the maximum score of 34 points, while Catalonia and the Balearic Islands score 28 each and the Canary Islands 26.
Madrid also sends 16% of its total healthcare spending to agreements with private providers. That is twice the average recorded across the other regions.
The lowest scores belong to La Rioja with 14 points, Murcia with 15.5, Extremadura with 17.5 and Castilla y León with 18.5. A low current score does not always mean slow growth.
Extremadura shows why. Its privatisation indicator has risen by 94.4% since 2014, even though the region still has one of the lowest overall scores. It started from a relatively small base.
Asturias has recorded the fastest rise, up 95.8% since 2014. Castilla-La Mancha follows with a 90% increase. The report says the process accelerated in Asturias during the past three years and in Extremadura since 2022.
Andalusia shows a different pattern. Its overall level of privatisation has grown by 70% over 12 years, but its position fell in the latest report. EFE links that change partly to an adjustment in budget allocations. It does not mean the region has abandoned private participation.
Sergio Fernández of the federation said a better position in the ranking does not mean that a region has a satisfactory model. Private involvement exists across all regional health services. The intensity and the methods differ.
The index covers more than direct contracts for medical services. It includes administrative concessions to manage public institutions, such as the hospital de Torrejón model in Madrid and the modelo Alzira in the Valencian Community.
It also counts state money sent to private insurers for civil servants covered through MUFACE, MUJEJU and ISFAS when they do not choose the SNS. Direct private purchases through insurance and household out-of-pocket spending are included too.
FADSP's index has a maximum of 34 points. It combines private insurance coverage, public agreements with private providers, private hospital resources, their use and household spending. The score is not a direct calculation of the share of public money transferred to commercial companies.
Catalonia needs an added qualification. FADSP says many of its agreements are with organisations that do not seek profit. The same index score therefore does not always mean the same structure or commercial motive in each region.
In 2025, residents of Galicia spent an average of 658.85 euros per person on healthcare from their own pockets, ahead of Madrid at 652.68 euros and the Basque Country at 651.69 euros. The regional average was 576.30 euros, while the gap between Galicia and Andalusia reached 167.17 euros.
Household costs are rising as well. Average out-of-pocket spending increased by 52.8% to about 576 euros. In 2025, Galicia recorded the highest figure at 658.85 euros per person. Madrid followed at 652.68 euros and the Basque Country at 651.69 euros.
Andalusia had the lowest figure. The gap between Galicia and Andalusia reached 167.17 euros.
La Vanguardia, reporting on the FADSP study, says private healthcare spending includes regional contracts, insurance payments and direct household costs. The number of people with private insurance has grown by 81% since 2014. It now covers about 21% of Spain's population.
Private infrastructure and household spending do not always rise together. In Galicia, private providers control 20% of hospital beds. The regional average is 26.5%.
Yet private providers hold 25% of Galicia's high-technology medical equipment. That is one of the highest shares in Spain. The figures show why the FADSP ranking is a composite measure, not a simple table of private beds or public contracts.
EFE also reports that private participation exists in every regional health system. The mechanisms and its intensity vary.
Waiting times connect the shift to access. Specialist appointments can take months. People with enough money can seek another route, while those without it remain in the queue.
The federation says this turns limited access into an equity problem. Timely care increasingly depends on household resources.
The report also points to wider social differences. People with lower levels of education, residents of depopulated areas, people without support networks and women face particular exposure to unequal access. People on lower incomes face it too.
Its authors say public-private cooperation does not meet the growing needs of an increasingly unequal society. They argue that it can deepen those differences instead.
The federation wants the defence of public healthcare to draw the same mobilisation seen around housing and speculation. With general elections called, it is asking each party to state which healthcare model it supports.
The concern about public protections also recalls an earlier rights report. The two subjects concern different institutions and conflicts.
Spain still has one of the world's strongest public healthcare systems, according to the report. The figures point to a system that keeps its international strength while access divides more sharply by income and geography.
Privatisation is not only a technical change when public money supports parallel routes to care. It is a political choice with measurable effects on equity and on the meaning of universal healthcare.
The rise in private insurance and the regional gap in out-of-pocket spending point to greater dependence on income and place of residence for access to additional care. These figures alone do not establish whether private provision is more or less efficient.
