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Fragmented Implementation and Resilient Universalism: Health Reforms in Spain (2000–2026) – An Analysis Using the Walt and Gilson Framework

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  • Azizi, Youssef

  • El Hiri, Abderrazak

Abstract

This study analyses the Spanish National Health System (2000–2026), examining reforms’ impact on universal health coverage (UHC) and financial protection under decentralization and fiscal constraints. To address this objective, a convergent mixed methods design combined Walt and Gilson’s health policy triangle with longitudinal analysis of health expenditures and the WHO UHC service coverage index. The findings indicate that the austerity measures (2012) shifted financial risk to households, increasing private and out-of-pocket spending without significantly reversing aggregate UHC scores. In contrast, rights-restoration (2018) and post-pandemic policies (2020–2026) renewed public investment and improved financial protection mechanisms. Overall, Spain shows resilient universalism, with institutional and social buffers preserving universality despite economic shocks.

Suggested Citation

  • Azizi, Youssef & El Hiri, Abderrazak, 2026. "Fragmented Implementation and Resilient Universalism: Health Reforms in Spain (2000–2026) – An Analysis Using the Walt and Gilson Framework," Revista Galega de Economía, University of Santiago de Compostela. Faculty of Economics and Business., vol. 35(2), pages 1-17.
    • Handle: RePEc:sdo:regaec:v:35:y:2026:i:2_8
    DOI: 10.15304/rge.35.2.11236
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