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Incentives for professionals in Spain

Partner Institute: 
University of Barcelona
Survey no: 
(13) 2009
Patricia Fernandez-Vandellos and Lluis Fornies-Vilagrasa
Health Policy Issues: 
Quality Improvement, Remuneration / Payment
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes yes no


The Spanish National Health Service (SNHS) has been decentralized into 17 regions in 2003. Still, human resource issues of civil servants in the health system have been regulated by national acts. The most recent develops, for the first time, a framework for professional development that recognizes personal skills and commitment. It tries to avoid a lineal model which is only based on seniority and consequently less motivational for professionals. It is now being implemented in many regions.

Purpose of health policy or idea

The main objective of this reform is to develop a professional career development among professionals working for the Spanish National Health Service (SNHS).

Characteristics and expected outcomes

  • To reward personal effort and professional skills.
  • To recognise comittment with the organisation.
  • To improve quality inside Public Health Services.

Main points

Main objectives

The national act 55/2003 is to develop a professional career development among professionals working for the Spanish National Health Service (SNHS).

Type of incentives

Financial incentives

Groups affected

Professionals working inside the Spanish National Health Service (SNHS)

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Characteristics of this policy

Degree of Innovation traditional innovative innovative
Degree of Controversy consensual consensual highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low low very high
Transferability strongly system-dependent system-neutral system-neutral

Political and economic background

Change based on an overall national health policy statement

55/2003 act

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes yes no

Origins of health policy idea

Before the current 55/2003 act for professionals inside the SNHS, human resources issues were regulated by pre-constitutional acts established during Franco's dictatorship (before 1978). These did not take into account any professional development except seniority, for any work category. Mainly because for years there had been a lack of professional incentives and regulations, in the late 90's some regions like Catalonia or Navarra launched pilot programs that started to carry out professional career development first for health professionals like physicians and nurses and then for the non-health professionals working inside the SNHS.

These pilot approaches definitely helped to further the implementation of the current act after the complete decentralization of health services into 17 regions had taken place in 2003. The Ministry of Health and regional governments on behalf of the central government were the main forces to develop this current act. They looked for a brand new policy, never seen before in any European country, that tries to reward good professionals and also allows them to leave an old-fashioned way of managment behind.

This new economic incentive scheme based on quality of care objectives for all workers and professional development has opened a new way of runnig business inside the public administration.

The 55/2003 act as an instrument gives a scenario and basic background for professional development. Every region then has to complete and define it with specific trade union consensus. This process is now taking place in many regions.

Central points in the act are:

  • It changes the retirement age for physicians: right before this law it was 70 years for physicians and it is 65 for all professionals.
  • It introduces two types of payments in wage: basic payment (depending on your professional development level) and payment by performance (depending on targeted goals). 

Before this current law, human resources issues inside the SNHS were regulated by pre-constitutional acts established during Franco's dictatorship (before 1978). These acts did not take into account any professional development except seniority. For the first time, a national act provides a framework to develop professional career among SNHS professionals so it can be considered a brand new policy.

Initiators of idea/main actors

  • Government
  • Providers
  • Patients, Consumers
  • Civil Society
  • Others

Approach of idea

The approach of the idea is described as:

Stakeholder positions

The Spanish government, particularly the Ministry of Health, has been the main promoter of the 55/2003 act and, consequently, the instigator of incentives and professional career development for workers of the SNHS. At the beginning, this policy was not well received by trade unions, but after consensus with the Ministry and regional governments, they strongly approve it. Health professionals also strongly agree with this policy as long as it allows them to improve their professional career. No main actors disagree with the act and its recent implementation in the regions.

Actors and positions

Description of actors and their positions
Spanish Ministry of Healthvery supportivevery supportive strongly opposed
Regional governmentsvery supportivevery supportive strongly opposed
Public Providersvery supportivevery supportive strongly opposed
Patients, Consumers
Patientsvery supportiveneutral strongly opposed
Civil Society
Trade Unionsvery supportivevery supportive strongly opposed
Professionals of the SNHSvery supportivevery supportive strongly opposed

Influences in policy making and legislation

The 55/2003 act gives an original framework to develop professional development and incentives for workers inside the SNHS. As a decentralized issue, specific degrees and career status should be discussed with trade unions at negotiating tables in every region. Due to these specific negotiations, professional incentives can be rather different among regions. In fact, some regional governments have applied an idea of progressing professional careers linearily following seniority, in contradiction with the new philosophy that aims to reward commitment and excellence among workers inside the organization.

Legislative outcome


Actors and influence

Description of actors and their influence

Spanish Ministry of Healthvery strongvery strong none
Regional governmentsvery strongvery strong none
Public Providersvery strongvery strong none
Patients, Consumers
Patientsvery strongneutral none
Civil Society
Trade Unionsvery strongvery strong none
Professionals of the SNHSvery strongvery strong none
Spanish Ministry of Health, Regional governments, Public Providers, Trade Unions, Professionals of the SNHSPatients

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Since decentralization in 2003, all the regions have implemented the 55/2003 act and therefore installed professional incentives for their workers. Professional careers may vary in every region due to local policies and trade union involvement at the negotiating tables. Workers inside the SNHS have improved their professional perspectives with this new act and trade unions have also participated in its implementation.

Some of the public health providers have already submitted a professional development career similar to the SNHS so it could be a good measure of success.    

No main obstacles have been observed since the implementation of this new professional policy.

Monitoring and evaluation

No major evaluations have been conducted since the new act has been submitted. Only the Catalan region has published a paper regarding the impact of economic incentives on the quality of professional life and end-user satisfaction in primary care and among health professionals (Gené-Badia et al 2007).

Dimensions of evaluation


Results of evaluation

The study performed by the Catalan region shows that the quality of professional life (QPL) after this policy implementation, has improved in terms of the dimension "perception of support from the management structure" among physicians (4,9 versus 5,2) as well as nurses (5,2 versus 5,6). Further, physicians perceived an increase in the dimension "demands made upon them" (6.1 versus 6.3), differently from the group of nurses (5,8 versus 5,9). Overall, user satisfaction did not vary significantly although a positive relationship was found between "perception of support from the management structure" and user satisfaction among nurses and a negative relationship between "demands upon them" and user satisfaction in the case of physicians. As a conclusion, this study reveals that incentives related to annual targets for quality of care may increase physicians' perception of burden and it may have a negative impact on consumer satisfaction. Incentives on long-term professional development seem to be related to an increase.

Expected outcome

To sum up, the log-term professional development submitted in the 55/2003 act has been well approved by professionals and trade unions inside the SNHS. Also, some SNHS providers have introduced a professional development career among their professionals quite similar to this one so this could be a good measure of policy success. Regarding direct effects on quality, access and equity further studies will be needed in order to know the real impact of this policy.   

Impact of this policy

Quality of Health Care Services marginal fundamental fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low very high very high


Sources of Information

  • [hompepage on internet]. Madrid: Ministerio de Sanidad y Política Social [updated 2009 April 6]. Available from:  
  • [homepage on internet]. Madrid: Boletín Oficial del Estado [updated 2009 April 6]. Available from:  
  • Gené-Badia, J, Escaramis-Babiano G, Sans-Corrales M. Sampietro-Colom L, Aguado-Mednguy F, Cabezas-Peña C et al. Impact of economic incentives on quality of professional life and on end-user satisfaction in primary care. Healthpol. 2007; 80:2-10.    

Author/s and/or contributors to this survey

Patricia Fernandez-Vandellos and Lluis Fornies-Vilagrasa

Suggested citation for this online article

Patricia Fernandez-Vandellos and Lluis Fornies-Vilagrasa. "Incentives for professionals in Spain". Health Policy Monitor, April 2009. Available at