Over the past three decades, European health systems have undergone major institutional and financial transformations, amplified by demographic aging, the emergence of chronic diseases, and imperatives of budgetary sustainability. Spain constitutes a particularly pertinent case study for examining how health system reforms influence equitable access to care and financial performance. Since the adoption of the General Health Law in 1986, the Spanish system has progressively decentralized, granting its 17 autonomous communities increasing autonomy in managing health services (López-Casasnovas & Rico, 2003). This decentralized architecture has generated substantial regional diversity but also persistent disparities in access and equity, revealing the gap between normative principles of universality and ground-level realities.
The period 2000-2026 has been marked by several critical reforms redefining universal health coverage (UHC) contours. temporarily restricted access to foreigners and increased co-payments, contravening universal access principles (). This restrictive reform was partially reversed in 2018 by , restoring access based on residency. These oscillations reflect fundamental tensions between financial sustainability, equity, and social protection, rendering rigorous analysis of measurable impacts imperative ().
Contemporary challenges justify this analysis. Spain’s aging population intensifies health financing pressures: the proportion aged 65 and over now exceeds 20%, exacerbating non-communicable chronic disease burden (). Simultaneously, emerging technologies—digital health, artificial intelligence, telemedicine—offer efficiency improvements while demanding substantial investments (). The 2008-2014 financial crisis demonstrated how macroeconomic shocks amplify health inequalities even within universal access systems, with disproportionate effects on low-income groups (). Population aging negatively impacts both healthcare expenditures and public revenues, creating dual financing pressures ().
Analysing Spanish health system reforms requires methodologically rigorous approaches combining financial indicators and UHC measures. UHC, measured according to Sustainable Development Goal 3.8.1, rests on a geometric mean of 14 tracer indicators covering reproductive, maternal, neonatal, paediatric services, infectious and non-communicable diseases, and accessibility (). Financial protection is evaluated by catastrophic health expenditure rates—exceeding 10% of household consumption or income—and out-of-pocket spending shares (). These indicators quantify whether reforms effectively improved equitable access without imposing unsustainable household financial burdens.
Evidence reveals that health equity requires systematic integration throughout health system design and implementation, not merely as an afterthought (). Decentralization to 17 autonomous communities produced remarkable regional diversity in resources and health outcomes. While studies demonstrate progressive regional convergence with efficiency gaps reduced by approximately 40% between 2002 and 2017, persistent disparities remain (). Substantial socioeconomic health inequalities persist since socioeconomic determinants—social class, education, income—significantly influence service access and utilization even within universal coverage contexts (). This fragmentation underscores the need for systematized equity assessment approaches.
On the financial dimension, health system sustainability becomes increasingly central. OECD projections indicate health spending could reach 11.8% of GDP by 2040 in OECD countries, creating significant budgetary and resource allocation challenges (). Health system governance—the ensemble of mechanisms regulating equitable resource al-location and accountability to all population groups—remains insufficiently developed in Spanish comparative reform analyses. Economic evaluation of health technologies has be-come essential for prioritizing resource allocation and approving new technologies; Spain’s adoption of systematic economic evaluation represents recent progress (; ). Fair financing processes require unified health insurance schemes, solid regulatory frameworks, and active purchasing mechanisms ().
The study focuses on the period 2000–2026 for several interrelated reasons. First, harmonised health expenditure data following the System of Health Accounts (SHA 2011) classification are consistently available from the WHO Global Health Expenditure Database from 2000 onwards, and the UHC service coverage index (SDG 3.8.1) is available from 2000. Second, this twenty-six-year window captures three major policy phases: the expansion and completion of decentralisation (2000–2009), the sovereign debt crisis and austerity reforms (2010–2014), the restoration of universal access (2015–2019), and the pandemic and post-pandemic recovery (2020–2026). The period 1986–1999 is treated as institutional context in the qualitative analysis (since it includes the foundational General Health Act and the early transfer of competences), but it is excluded from the quantitative longitudinal analysis because comparable SHA 2011 expenditure series and UHC index data are not available for those years.
The general objective of this study is to analyse how successive health reforms in Spain between 2000 and 2026 have shaped universal health coverage (UHC), financial protection and health system performance within a highly decentralised National Health System, using the Walt & Gilson policy analysis framework to integrate context, content, process and actors.
Three research questions guide the analysis:
Two working hypotheses are formulated to guide interpretation (without being tested through causal models). First, the austerity period (2010–2014) is expected to be associated with a relative increase in private and out-of-pocket expenditure and a stagnation or slowdown in UHC gains, while aggregate UHC scores may remain stable or continue rising slowly because of time lags and the composition of the tracer indicators. Second, the post-2015 and post-2020 periods (restoration of rights and pandemic–recovery) are expected to show a partial reversal of private financing shares, a stabilisation or slight decline of out-of-pocket spending relative to current health expenditure, and renewed progress in the UHC index, driven by legal restoration of universal access and EU-funded investment plans.
Developed in 1994, Walt and Gilson’s health policy triangle constitutes a foundational analytical instrument for deconstructing policy formulation and implementation processes (; ). The framework posits that health policies emerge from dynamic interaction among four interdependent pillars: Context, Content, Process, and Actors (Figure 1). Critically, this framework rejects deterministic accounts. Rather, it emphasizes that policy constitutes a contingent outcome of contested power relations and divergent preferences, where structural conditions create possibility spaces but do not dictate predetermined trajectories ().
Beyond , complementary frameworks like Kingdon’s Multiple Streams Framework (MSF), Sabatier’s Advocacy Coalition Framework (ACF), and Multi-Level Governance (MLG) provide vital insights into opportunity windows, actor belief systems, and supranational-regional interplay in decentralised settings. In this article, serves as an integrative meta-framework capable of absorbing these multilevel dynamics within its four original dimensions, providing a streamlined but comprehensive analytical lens.
Institutional Foundations. Spain’s 1978 Constitution constitutes the institutional foundation for subsequent health system transformations (). By constitutionally recognizing health protection as a right (Article 43) and establishing 17 Autonomous Communities with devolved authority, the constitutional design enabled progressive decentralization. This devolution process extended across more than two decades (1981-2002), creating persistent asymmetries in governance experience and resource availability between “historical” communities and those under the general regime. Fiscal asymmetries further differentiate regional capacities, with regions like the Basque Country and Navarre operating under a foral system providing substantially more fiscal autonomy. This decentralization paradoxically enhanced local responsiveness—allowing regions like Catalonia and the Basque Country to pioneer integrated care models—while generating policy fragmentation and uneven diffusion of innovations ().
Economic Crisis and Austerity Shock (2012-2015). The 2008 financial crisis and subsequent sovereign debt crisis imposed unprecedented fiscal constraints on the Spanish health system (). Between 2012 and 2015, cumulative public health budget reductions reached 900 million to 2.1 billion euros annually. Beyond aggregate budget cuts, austerity measures restructured financing mechanisms, increased nurse workloads, reallocated resources away from social services, and introduced pharmaceutical cost-sharing arrangements (). Critically, the empirical literature documents that austerity-driven policy changes generated demonstrable health equity consequences, contradicting theoretical assumptions that efficiency gains would offset coverage losses.
Demographic and Migration Transitions. Spain’s demographic profile shifted markedly: resident foreign-born populations increased from 2.7% (1996) to 19.6% (2025), predominantly dependent on public health services (). Concurrent population aging expands chronic disease burden and complicates resource allocation. These demographic realities create dynamic pressure on coverage boundaries and necessitate policies explicitly addressing health equity for vulnerable populations.
Pharmaceutical Cost-Sharing and the Logic of Austerity. The Spanish National Health System (SNS) traditionally funded care through general taxation with universal, near-free-at-delivery provision. Successive reforms introduced cost-sharing mechanisms, particularly in pharmaceutical coverage. instituted income-dependent copayment structures (10-60% depending on employment and income status), ostensibly designed to promote allocative efficiency and fiscal sustainability (). Empirical evaluation reveals that this policy logic did not materialize as intended; cost-sharing functioned as a psychological and practical access barrier, particularly among low-income populations ().
Universal Coverage Under Strain:. The 1986 General Health Act established universal coverage as a foundational principle. Yet introduced a radical rupture: eligibility criteria shifted from universal residency to legal status and employment status, effectively excluding approximately 870,000 undocumented migrants from publicly funded services (). Its justification invoked fiscal emergency and immigrant cost-containment narratives, yet empirical studies document that excluded populations exhibited elevated mortality and morbidity (). Substantially, provoked sustained political mobilization. By 2018, reinstated universal access based on residency, returning to the coverage principle abandoned in 2012 ().
Organizational Innovation: Integration and Chronic Care Management. Since 2019, SNS organizational reforms prioritize primary health care strengthening and integration across care levels (). The Strategic Framework for Primary and Community Care (2019) explicitly reorients services toward health promotion, disease prevention, and integrated chronic disease management.
: Emergency Procedure and Fragmented Implementation. The government’s 2012 response to fiscal crisis—adoption of via emergency decree procedure—bypassed normal parliamentary deliberation. Paradoxically, despite centralized national enactment, implementation exhibited remarkable regional heterogeneity. Systematic policy analysis across 13 Autonomous Communities identified five distinct interpretive configurations, ranging from strict conformity to explicit policy reversal ().
Interterritorial Coordination: The Interterritorial Council and Coordination Gaps. Established by the 2003 Law on Cohesion and Quality, the Interterritorial Council of the National Health System (CISNS) functions as Spain’s primary coordination mechanism. However, CISNS effectiveness remains constrained by underlying power asymmetries and interests’ divergence, possessing limited capacity to enforce uniform implementation or override regional priorities when they conflict with national directives ().
The Ministry of Health exercises residual coordination authority, pharmaceutical regulation, and equity monitoring functions, while regional health authorities wield substantive planning, financing, and provision power (). Health professionals constitute critical implementation actors, though qualitative research documents that excessive workload and inadequate research infrastructure constrain their capacity to implement person-centred care (). Non-state actors—human rights organizations, medical associations, patient advocacy groups—shaped reform trajectories by reframing health policy as justice questions. Organizations including the Center for Economic and Social Rights (CESR) documented the health consequences of exclusions, contributing materially to 2018 policy reversal (). Transnational organizations exercise influence through norm-setting and comparative legitimation, establishing reference frames that subtly reshape domestic policy logic.
To provide a comprehensive evaluation of the Spanish health system’s evolution from 2000 to 2026, this study adopts a convergent mixed-methods design. This approach triangulates qualitative policy analysis with quantitative longitudinal assessment of financial and performance indicators.
The qualitative analysis is grounded in the Health Policy Triangle framework developed by Walt and . This model was selected to deconstruct reforms beyond their technical content by examining the interdependence of Context, Content, Process, and Actors.
Qualitative Coding and Analytical Protocol. Data processing involved deductive thematic analysis. The documentary corpus, including official legislative texts from the Boletín Oficial del Estado (BOE), strategic plans, and Scopus-indexed academic literature, was manually coded according to the four predefined dimensions. Iterative categorization was used to extract policy goals, mechanisms, and involved stakeholders for each major reform event, ensuring inter-coder reliability through consensus-building.
We constructed a longitudinal dataset (2000-2025) using official data from the World Health Organization (WHO) Global Health Expenditure Database (GHED) () and the Global Health Observatory.
Selected Indicators. Four key indicators were selected to track financing trends and coverage performance. The definitions strictly follow the System of Health Accounts (SHA 2011) classification established by the OECD, Eurostat, and WHO (). Specifically: Current Health Expenditure (CHE), Domestic General Government Health Expenditure (GGHE-D), Domestic Private Health Expenditure (PVT-D), and Out-of-Pocket Expenditure (OOPS). In addition, the UHC Service Coverage Index (SDG 3.8.1) was utilized.
Statistical Analysis. Data processing involved the calculation of univariate descriptive statistics (Arithmetic Mean, Standard Deviation, Minimum, Maximum). To measure the directional velocity of change over time, the Compound Annual Growth Rate (CAGR) was calculated:
Given that National Health Accounts data represent macro-level national aggregates rather than sample estimates, descriptive statistics (mean, SD, and sample size n in years) are sufficient; confidence intervals are not applicable in this context.
Clarification on analytical approach. The quantitative analysis is purely descriptive. No causal identification strategy is employed. The periodization around major reforms is used solely to structure the description of trends and to organise the narrative triangulation with the qualitative strands.
Table 1 provides an overview of how research objectives, dimensions, data types, sources and analytical approaches are aligned. No additional methodological tools are introduced; the table only clarifies the existing design.
Based on the legislative history of the Spanish National Health System (SNS), the analysis is segmented into four distinct political-economic periods: Expansion & Decentralization (2000-2009), Crisis & Austerity (2010-2014), Restoration of Rights (2015-2019), and Pandemic & Recovery (2020-2026).
Table 2 describes the evolution of health financing indicators. During the Expansion period (2000-2009), Public Expenditure (GGHE-D) grew at a CAGR of +3.81%, peaking at an average of 5.60% of GDP. Following the 2010 financial crisis, the Austerity period (2010-2014) saw a contraction in GGHE-D (CAGR -3.78%), while Private Expenditure (PVT-D) surged by +10.67% annually. Out-of-pocket spending (OOPS) relative to current health expenditure increased from an average of 22.90% to 23.00%, reaching a peak of 25%. The post-pandemic phase (2020-2023) exhibited a renewed influx of public funding (mean GGHE-D 7.50%) and a relative contraction in private financing shares (Figure 2).
Source: Authors’ elaboration based on data from WHO GHED, SHA 2011 classification
Table 3 presents the UHC Service Coverage Index. Despite the reduction in public expenditure and rise in OOPS documented during the Austerity period (2010-2014), the aggregate UHC index continued to rise slightly, moving from a mean of 77.33 (2000-2009) to 80.50 (2010-2014), growing at +0.31% annually. The index maintained a steady positive trajectory through the Restoration (+0.30%) and Pandemic (+0.72%) phases, culminating in a mean score of 83.67 by 2025.
Source: Data from WHO Global Health Observatory
The qualitative coding mapped legislative events against the framework. Table 4 details the foundational, expansion, and austerity reforms (1986-2015), showing a reliance on emergency decrees during fiscal crises (e.g., ) and centralized state actors bypassing regional consultation.
Source: Adapted from and , with authors’ elaboration based on BOE legislative texts
Table 5 outlines the post-2018 rights-restoration and pandemic recovery legislation, highlighting a shift toward consensus-based strategic frameworks, the reinstatement of universal rights, and massive EU-funded structural projects in-volving broader multi-level actor coalitions.
Source: Adapted from and , with authors’ elaboration based on BOE legislative texts
The primary objective of this study was to analyse how successive health reforms in Spain between 2000 and 2026 have shaped universal health coverage (UHC), financial protection and health system performance within a highly decentralized National Health System. By combining longitudinal financial and UHC indicators with a structured policy analysis, the study aimed to move beyond purely descriptive expenditure trends to explore the intersections between economic context, legislative content, and actor dynamics.
Overall, the findings indicate that Spain maintained a gradual but continuous increase in the UHC service coverage index. However, this aggregate progress masks marked intra-period differences in risk-sharing. The austerity years after 2010 were characterized by a retrenchment of public effort and a sharp rise in private expenditure and out-of-pocket payments. This trajectory reflects a temporary "financial risk shifting" away from the state and onto households. Conversely, the post-2018 and post-COVID phases were associated with stabilized financial protection indicators, combining renewed public investment with modest reductions in household financial burden.
The application of the framework reveals that these financial and coverage patterns closely track shifts in reform instruments. The transition from restrictive measures () to rights-restoring legislation () highlights the evolving coalitions of state, professional, civil society and international actors. This dynamic illustrates the concept of "resilient universalism," wherein systemic adaptations, legal reversals, and social mobilizations counteracted restrictive policies over time, preserving the egalitarian foundations of the system against macroeconomic shocks.
A noteworthy finding is that the aggregate UHC service coverage index continued to rise during the Crisis–Austerity period (2010–2014), even though public expenditure as a share of GDP declined and out-of-pocket spending increased. This apparent paradox can be explained by the composition of the UHC index itself. The index is a composite of 14 tracer indicators that mainly capture the availability of essential services (e.g., antenatal care, skilled birth attendance, immunisation) rather than measuring financial protection or access barriers related to copayments. During the austerity period, these tracer services were largely maintained. Furthermore, the index does not directly measure forgone care due to cost, nor does it adequately capture the exclusion of undocumented migrants, which affected a relatively small population in national aggregates. This dissociation underscores a critical limitation of the UHC index as a standalone metric: a country can show rising service coverage while household financial risk worsens ().
The findings converge with previous work documenting that decentralization in Spain simultaneously enabled innovation and produced persistent regional disparities in efficiency and access (). The observation that austerity-driven reforms shifted financial burdens onto households aligns with previous literature documenting increased out-of-pocket spending and access barriers for vulnerable groups following (; ).
However, this article diverges from much of the existing Spanish literature by systematically integrating all four dimensions of the framework into a longitudinal quantitative analysis. It nuances the optimistic view that the post-crisis period fully restored pre-austerity protection levels, observing instead that private spending and out-of-pocket shares remain structurally higher than in the early 2000s despite the reversal of the most re-strictive measures (). This suggests that some distributional effects of austerity became embedded in the financing mix.
Several limitations must be acknowledged. First, the quantitative design is purely descriptive and does not permit causal identification of the effects of individual reforms. Statements regarding associations between reforms and financial outcomes should not be interpreted as causal estimates. Second, there is potential endogeneity between the macroeconomic context and policy decisions; for instance, the improvement in UHC scores may be partly attributable to broader economic recovery rather than solely to reform reversals. Third, the reliance on national-level aggregate indicators masks within-country inequalities and sub-national het-erogeneity in access and financial burden. Finally, while theoretical frameworks like the Multiple Streams Framework (MSF) and Advocacy Coalition Framework (ACF) were introduced conceptually to complement , they were not fully operationalized through empirical qualitative micro-data, such as direct interviews with policymakers or inter-coder reliability metrics beyond thematic consensus.
From a policy perspective, the Spanish experience offers crucial practical implications for decision-makers in decentralized European systems. Protecting UHC requires more than preserving legal entitlements; it demands the active management of financial risk-sharing and the reinforcement of binding interterritorial coordination mechanisms to prevent reforms from generating de facto regional inequities. The Interterritorial Council must be strengthened to move beyond simple consensus-building toward enforcing common equity standards across regions.
For future comparative research, scholars should prioritize quasi-experimental evaluations (e.g., difference-in-differences, interrupted time series) using individual or household-level micro-data to accurately identify the causal impacts of specific reforms on catastrophic health expenditures across different socioeconomic groups. Furthermore, integrating detailed regional comparisons to fully operationalize ACF and MLG dynamics will clarify how local governance and fiscal autonomy mediate the translation of national reforms into ground-level practice (Figure 3).
The analysis of the Spanish healthcare system reforms between 2000 and 2026 reveals a trajectory defined by a persistent tension between budgetary sustainability imperatives and a deep-rooted commitment to the principles of universalism. The application of the Walt and Gilson framework demonstrated that system transformations are the product of complex interactions between successive economic crises, sometimes fragmented decision-making processes, and highly resilient coalitions of actors.
Decentralization acted as a double-edged mechanism, fostering local innovation while generating territorial disparities and implementation complexities. At the same time, the concept of "resilient universalism" emerged as a tangible institutional reality. Despite austerity shocks that were associated with a temporary increase in the financial burden on households, the system executed legal and political readjustments to stabilize its egalitarian foundations. The sustainability of the Spanish model will ultimately depend on finding a new equilibrium where financial stability is not achieved at the expense of equitable access, ensuring that health protection remains an inalienable pillar of the social contract.
The authors gratefully acknowledge the support of Sidi Mohamed Ben Abdellah University, Faculty of Legal, Economic and Social Sciences (Fez), and the Interdisciplinary Laboratory of Research in Economics, Finance and Organizational Management. We also thank the Ministry of Health of Spain and the World Health Organization for providing access to data used in this study, as well as colleagues and anonymous reviewers whose comments helped improve the manuscript.
Conceptualization, Y.A.; Methodology, Y.A.; Software, Y.A.; Data acquisition, A.E.H..; Analysis and interpretation, Y.A.; Writing- Preparation of the draft, Y.A.; Writing-Revision & Editing, A.E.H. All authors read and agree with the published version of the manuscript.
1
Abásolo, I., Saez, M., & López-Casasnovas, G. (2017). Financial crisis and income-related inequalities in the universal provision of a public service: The case of healthcare in Spain. International Journal for Equity in Health, 16, Article 134. https://doi.org/10.1186/s12939-017-0630-y
2
Armenteros-Ruiz, T., Ballesteros-Ron, A., Rodriguez-Mañero, M., & Reyes-Santías, F. (2024). Evaluating the decentralisation of the Spanish healthcare system: A data envelopment analysis approach. BMJ Open, 14(3), e076853. https://doi.org/10.1136/bmjopen-2023-076853
3
Bernal-Delgado, E., Angulo-Pueyo, E., Ridao-López, M., Urbanos-Garrido, R. M., Oliva-Moreno, J., García-Abiétar, D., & Hernández-Quevedo, C. (2024). Spain: Health system review. Health Systems in Transition, 26(3), 1–187. https://pubmed.ncbi.nlm.nih.gov/40094303/
4
Blasco-Palau, G., Prades-Serrano, J., González-Chordá, V., Matalonga-Albiol, C., & Montiel, N. (2023). Socioeconomic inequalities as a cause of health inequities in Spain: A scoping review. Healthcare, 11(23), Article 3035. https://doi.org/10.3390/healthcare11233035
5
Bouckley, T., Peiris, D., Nambiar, D., Mishra, S., Sood, T., Purwar, P., Elshaug, A. G., Landon, B. E., Pearson, S.-A., Huckel Schneider, C., & Schierhout, G. (2025). Addressing health equity during design and implementation of health system reform initiatives: A scoping review and framework. International Journal for Equity in Health, 24, Article 68. https://doi.org/10.1186/s12939-025-02436-z
6
España. Jefatura del Estado. (2012). Real Decreto-ley 16/2012, de 20 de abril, de medidas urgentes para garantizar la sostenibilidad del Sistema Nacional de Salud y mejorar la calidad y seguridad de sus prestaciones. Boletín Oficial del Estado, 98, 31278–31312. https://www.boe.es/eli/es/rdl/2012/04/20/16
7
Gilson, L., & Walt, G. (2008). Doing health policy analysis: Methodological and conceptual reflections. Health Policy and Planning, 23(5), 308–317. https://doi.org/10.1093/heapol/czn024
8
Gogishvili, M., Billock, R., Ravallon, H., Sasson, A. D., O’Connor, D. R., & Altice, F. L. (2021). Policy implementation analysis on access to healthcare and HIV services among undocumented immigrants in Spain. BMJ Open, 11(6), e045626. https://doi.org/10.1136/bmjopen-2020-045626
9
Hajji, O., & Tabar, M. (2025). Systematic review of financing functions for universal health coverage in low- and middle-income countries. Public Health Reviews, 46, Article 1607745. https://doi.org/10.3389/phrs.2025.1607745
10
López-Bastida, J., Oliva, J., Antoñanzas, F., García-Altés, A., Gisbert, R., Mar, J., & Puig-Junoy, J. (2010). Spanish recommendations on economic evaluation of health technologies. The European Journal of Health Economics, 11(5), 513–520. https://doi.org/10.1007/s10198-010-0244-4
11
López-Casasnovas, G., Costa-Font, J., & Planas, I. (2005). Diversity and regional inequalities in the Spanish 'system of health care services'. Health Economics, 14(S1), S221–S235. https://doi.org/10.1002/hec.1038
12
Morgan, D., & Astolfi, R. (2014). Health Spending Continues to Stagnate in Many OECD Countries (OECD Health Working Papers No. 68). OECD Publishing. https://doi.org/10.1787/5jz5sq5qnwf5-en
13
OECD [Organisation for Economic Co-operation and Development]. (2024). Fiscal sustainability of health systems. OECD Publishing. https://doi.org/10.1787/880f3195-en
14
Ramaswamy, A., & Aravind, K. (2025). Role of digital health technologies in improving universal health coverage in sub-Saharan Africa. Frontiers in Digital Health, 7, Article 1391500. https://doi.org/10.3389/fdgth.2025.1391500
15
Real Decreto-ley 7/2018, de 27 de julio, sobre el acceso universal al Sistema Nacional de Salud, Boletín Oficial del Estado No. 183 (2018). https://www.boe.es/eli/es/rdl/2018/07/27/7
16
Simó Miñana, J. (2015). Copago en farmacia de receta en la sanidad pública española: Certezas, riesgos y selección de riesgos. Atención Primaria, 47(10), 669–673. https://doi.org/10.1016/j.aprim.2015.06.010
17
Urbanos-Garrido, R. M., & Angulo-Pueyo, E. (2024). Evaluating the decentralisation of the Spanish healthcare system: Efficiency analysis and regional performance disparities. BMJ Open, 14(3), e076853. https://doi.org/10.1136/bmjopen-2023-076853
18
Vallejo-Torres, L., Oliva-Moreno, J., & Lobo, F. (2025). Exploring the uptake of economic evaluation in Spanish reports positioning medicines for public reimbursement. Health Economics, Policy and Law, 20(3), 233–245. https://doi.org/10.1017/S1744133124000264
19
Walt, G., & Gilson, L. (1994). Reforming the health sector in developing countries: The central role of policy analysis. Health Policy and Planning, 9(4), 353–370. https://doi.org/10.1093/heapol/9.4.353
20
WHO [World Health Organization]. (2019). Universal health coverage (UHC) service coverage index: SDG indicator 3.8.1. https://www.who.int/data/gho/indicator-metadata-registry/imr-details/4834
21
WHO [World Health Organization]. (2024). Global Health Expenditure Database (GHED). https://apps.who.int/nha/database
22
Williamson, E., Akhtar, Z., Marques, H., Thakur, S., & Datta, S. (2025). Health financing policies for aging populations. Frontiers in Public Health, 12, Article 1423560. https://doi.org/10.3389/fpubh.2025.1423560
23
World Bank. (2020). Catastrophic and impoverishing health expenditure. https://www.worldbank.org/en/topic/health/brief/health-financing
24
Zurynski, Y., Herkes-Deane, J., Holt, J., McPherson, E., Lamprell, G., Dammery, G., Meulenbroeks, I., Halim, N., & Braithwaite, J. (2022). How can the healthcare system deliver sustainable performance? A scoping review. BMJ Open, 12(5), e059207. https://doi.org/10.1136/bmjopen-2021-059207
