This chapter will focus on the following cost containment measures.

Changes in the system of financing Spanish hospitals, entailing a move away from reimbursement methods to the purchasing of services based on activity, as evidenced by the evolution of the Catalan contracting-out method since 1986, the 1991 State Hospital Contracts Programme (Contrato Programa), and some other initiatives in the Basque Region.

The creation in 1993 of a negative list of drugs which could no longer be reimbursed by social security (800 brand name products); some very recent experiments (for example in Valencia in 1997) on reference pricing (the maximum that the authority is willing to pay) for the most commonly prescribed drugs and proposals for pharmaceutical copayment increases.

Changes derived from the primary health care reform, begun in 1984 and still under way, involving the departure from a system based on capitation and hours of work to a system closely related to salaries and full-time employment in the new Health Centres.

Efforts to create a basic package of publicly financed health care, best represented by the Guaranteed Health Care Entitlement of 1995.

An analysis of the diversity in the way health services are managed across the decentralized Spanish autonomous communities.

402 Proposals to extend the MUFACE system (a publicly financed choice of public or private health insurer) currently restricted to civil servants, to the rest of the population.

The following overview of the Spanish health care system will attempt to set these cost containment measures in the relevant context.