“It is paradoxical that a country with one of the highest life expectancies in the world (Top 5 globally) and a constantly growing population of over 65s devotes such limited resources to their care. How then does the system sustain itself? The answer is simple and well-known. Thanks to a safety net that does not count in public budgets, informal care. If we add the cost of informal care (valued at replacement cost or opportunity cost), the real total expenditure in Spain would soar to between 1.2% and 1.7% of GDP, almost double the current figure (0.9%)”. And close to the OECD average (1.8%).
Text: Sergi Jiménez-Martín (UPF, BSE and FEDEA) and Analía Viola (FEDEA)
FEDEA Notes 2026/04. January 2026
The long-term care system (LTC) in Spain has undergone significant transformations since the approval of Law 39/2006, known as the Law for the Promotion of Personal Autonomy and Care for People in Situations of Dependency (SAAD).
1
Introduction
Before its implementation, the Spanish model was characterised by a strongly familial approach, with very low levels of spending compared to the European context. The SAAD represented a decisive advance, universalising the right to receive a benefit and establishing a state framework for financing and coordination.
Despite these advances, significant challenges persist: high and unequal waiting lists among autonomous communities, strong dependence on informal care, limited coverage of professional services, and tensions in system financing.
It will soon be 20 years since the approval of the Law on Autonomy and Care for Dependency (SAAD). The question we must ask ourselves today, with the data in hand, is whether this right has been consolidated or whether, on the contrary, we remain trapped in a scheme of half-fulfilled promises, unstable financing, and a certain territorial inequality that we still do not know whether it is positive (derived from adaptation to people and territory) or negative (based on arbitrary criteria).
In this document, we analyse some problems and challenges of implementing dependency care in Spain. First, we begin with a brief analysis of the situation in Spain in some dimensions of LTC in comparative perspective. We will then analyse the institutional context. Subsequently, we examine employment in the dependency sector and emphasise the indicators of spending on dependency and its financing. Finally, we present the conclusions.
2
Long-term care in comparative perspective
This section presents a comparative analysis of LTC in Spain and various European countries, aiming to contextualise the performance of the Spanish system within an international framework. To do this, we examine three key indicators that allow us to assess some dimensions of dependency care: 1. limitations in basic activities of daily living (ADLs) such as dressing, bathing, eating, and moving, 2. coverage of dependency aids, and 3. spending on LTC.
The ageing of the population inevitably increases the demand for long-term care. Knowing how many people have difficulties performing daily activities is fundamental, as this indicator provides a direct approximation of the level of dependency existing in society. On average in the EU27, 47% of those over 65 report moderate or severe limitations in ADLs, decreasing by 4 percentage points compared to 2023. Spain is below the European average, with 40% of those over 65 reporting limitations in 2024, improving compared to 2023 (50%).
“If we add those waiting for degree assessment (136,009 people), those waiting for the Individual Attention Programme (PIA) (123,857 people), and those who have had the PIA approved but are waiting to receive the benefit or service established by that PIA (26,995 people), the figure exceeded 286,000 people by mid-last year”
The LTCs tend to be higher in northern countries, which traditionally have more developed systems. Nevertheless, Spain has made notable progress in recent years. Across the OECD, most benefits are provided at home, with an average of 11.6% in 2023. In the case of Spain, this orientation towards home care is even more pronounced: in 2024, 14% of people received support in their homes, compared to 2.3% who did so in institutions. There has been a notable increase of almost 5 percentage points in the percentage of people receiving aid compared to 2019.
Spending on LTC as a percentage of GDP. Selected OECD countries. 2019-2024
2024: only Canada, Denmark, Iceland, Ireland, Italy, South Korea, Luxembourg, Netherlands.
Finally, recent data on spending on LTC shows that Spain remains lagging behind in the European context. The financial effort devoted to LTC in Spain is around 0.9–1% of GDP, a significantly lower proportion than the OECD average, which reaches 1.8%. The gap is even more evident when compared to northern European countries, where investment ranges from 3% to 4% of GDP. Spending on LTC as a proportion of total healthcare spending shows significant differences between countries. In 2023, Spain allocated 10.2%, a figure below the OECD average (13.7%). The distance is even greater when compared to northern European countries, where this percentage ranges from 20% to 30%. Overall, the data indicates that, despite progress, Spain's relative effort remains low compared to European nations with more consolidated care systems.
3
The SAAD
To understand the magnitude of the challenge, it is imperative to remember where we come from. Before the implementation of the SAAD, the care model in Spain was eminently “familialist” (Jiménez and Viola, 2024a). Care for the elderly fell almost exclusively on households (read: on women), and public provision was limited to services offered mainly at the local level, with discretionary financing conditional on the beneficiary's resources.
The Dependency Law of 2006 represented a paradigm shift: the universalisation of access regardless of age, demographic characteristics, or resources. However, the implementation of this right has been, to be generous, bumpy. After a hopeful start, the system suffered the scythe of the financial crisis, with severe cuts to the contribution of the general state administration (AGE) in dependency financing between 2012 and 2019, followed by a strong expansion from 2020 onwards.
The financing of the SAAD comes from a combination of resources from the Central Government, the Autonomous Communities, and user copayments. In the first years after the approval of the SAAD, the financial burden fell mainly on the autonomous communities. However, in recent years, the Central Government has increased its financial contribution through significant budget increases, which has helped to partially address the funding shortfall that plagued the system in its early days (Costa-Font et al., 2025). The design is universalist, but the implementation is decentralised, leading to notable variations in response times, intensity of benefits, and service portfolio.
3.1. Waiting lists and the limbo of dependency
One of the most serious problems of the system has been the so-called limbo of dependency: the prolonged administrative process in which people become trapped who, despite having their right to a benefit recognised, have not yet accessed it, or do not receive it in time because they die in that process. Hernández-Pizarro (2016) estimated that between 5% and 10% of the approximately 46,000 people who die each year while waiting for an assessment or the allocation of services could have lived significantly longer had they received the benefits at the right time.
Evolution of the “limbo of dependency” in Spain. 2009-2024
The limbo of dependency reached its peak in 2015 when it affected 385,000 people; by 2024, this figure had decreased to 118,333 (7% of the total beneficiaries with rights). The Shock Plan initiated in 2021 contributed to the reduction (Jiménez and Viola, 2022), but regional differences persist: while Castilla y León or Aragón present almost zero percentages, Catalonia and the Basque Country maintain high figures.
However, if we add those waiting for degree assessment (136,009 people), those waiting for the Individual Attention Programme (PIA) (123,857 people), and those who have had the PIA approved but are waiting to receive the benefit or service established by that PIA (26,995 people), the figure exceeds 286,000 people by mid-2025.
3.2 Territorial dispersion: 17 care systems
In Spain, approximately 40% of the benefits granted are currently economic (especially for family care-PCF) and 60% correspond to professional services. The 2006 law was born with the intention of providing services (day centres, residences, professional home help) to professionalise the sector and thus relieve women of the burden of informal care. However, reality has imposed economic benefits (more intensely in the early days of the SAAD), often cheaper for the administration but socially less efficient.
“The service portfolio varies greatly among the autonomous communities, which assume 60/70% of the spending. This generates 17 distinct models. In Catalonia, Murcia, and the Balearic Islands, economic benefits for family care account for 45% of the total. In the Basque Country (where tele-assistance represents 26%) or Castilla y León, they have opted for a portfolio of professional services, with much lower rates of economic benefits”
Decentralisation has allowed services to be adapted to the territory, but it has also generated significant disparities in access and benefit portfolios. The actual service portfolio varies widely among communities, generating 17 distinct care models. In Catalonia, Murcia, and the Balearic Islands, economic benefits for family care represent about 45-46% of the total. In contrast, regions like the Basque Country (for example, tele-assistance represents about 26%) or Castilla y León have decisively opted for a portfolio of professional services, with much lower rates of economic benefits.
Average time from application to resolution of benefit (in days) by autonomous community. June 2024.
In terms of processing times, there is also a great divergence. Thus, while in autonomous cities like Ceuta or in communities like Castilla y León the average time from application to resolution of the benefit is reasonable, in regions like Murcia, the Canary Islands, or Andalusia the times are exasperatingly long. This is not just an administrative problem; it is a basic equity issue.
4
Employment in the dependency sector
We should not make the mistake of analysing dependency solely as an expenditure item. It is also an investment with a tangible social and economic return. The dependency sector has become a significant employment engine in Spain (Jiménez and Viola, 2024b).
“We should not make the mistake of analysing dependency only as an expenditure item. According to data from the EPA for Q2 2024, the sector employs more than 700,000 people, representing 3.2% of total employment, with a year-on-year growth of 12%. 82% are women and 23% were born abroad”
According to data from the EPA for the second quarter of 2024, the sector employs more than 700,000 people, which represents 3.2% of total employment and shows a year-on-year growth of 12%. It is a sector in sustained expansion since 2018 that does not know the crisis of demand. The participation of employment in dependency exceeds 4% of the total in regions like Extremadura, Castilla y León, the Basque Country, or Galicia. However, working conditions are not entirely as desired. We can distinguish some characteristics of the labour market in this sector:
- Low wages: Relative remuneration does not seem to hit bottom, raising the question of whether we are really valuing care socially as it deserves.
- High temporary and part-time work, although the labour reform seems to have had some impact on permanent hiring.
- Extreme feminisation: 82% of workers are women.
- Dependence on immigrant labour: It is a key entry sector, where 23% of workers were born outside Spain.
5
Are we spending too much or too little?
There is a recurring narrative about the unsustainability of social spending. However, when comparing Spain with the EU, the reality is that our financial effort in long-term care is, at the very least, moderate.
As we have seen, in terms of GDP, Spain allocates between 0.9% and 1% to long-term care. This figure not only pales in comparison to the OECD average (1.8%), but it is light years away from northern European countries, which invest between 3% and 4% of their national wealth in protecting their elderly. The same goes for the relative effort within the healthcare budget, with 10.2% of total health spending allocated to dependency in Spain compared to 13.7% in the OECD average and over 20% in Nordic countries.
It is paradoxical that a country with one of the highest life expectancies in the world (Top 5 globally) and a constantly growing population of over 65s devotes such limited resources to their care. How then does the system sustain itself? The answer is simple and well-known: thanks to a safety net that does not count in public budgets, informal care (Jiménez and Viola, 2024a).
If we attempt to monetise this hidden cost –the “great forgotten cost”– the figures change radically. Estimates we have made within the framework of a project on international long-term care (Costa-Font et al, 2025) indicate that, if we add the cost of informal care (valued at replacement cost or opportunity cost), the real total expenditure in Spain would soar to between 1.2% and 1.7% of GDP, almost double the current figure. That is to say, a substantial part of the dependency bill is still being paid by families with their time and health.
6
Who finances it?
The financing system is complex and a constant source of tensions between the central government and the autonomous communities. Originally, a balanced co-responsibility was proposed, but in practice, the communities have ended up assuming between 60% and 70% of the spending.
However, it is notable that the general contribution of the State (AGE) has increased since 2021, rising from 16% to 27% in 2024, which is also reflected in the General State Budgets. As can be seen, the state budget has grown significantly since 2021 (+68% in 2021, +23% in 2022, +21% in 2023), reaching 3,522 million.
However, the contributions from both sides often do not respond to observable and reasonable criteria. We observe that the per capita expenditure of the AGE and the autonomous communities responds to theoretical needs (measured by the fraction of those over 80). We observe that currently, AGE financing is somewhat more sensitive to theoretical needs. This becomes especially evident when we correct for spending only on those over 65, as the positive slope disappears for the AGE and even turns negative for the communities. This is because many communities react (negatively) to improvements in AGE contributions and do not consider stable financing of dependency to be one of their priorities.
Finally, there is a third payer who is talked about less: the user. It is often cited that copayments contribute around 20% of the financing (Jiménez and Viola, 2024b). Recent studies (Del Pozo, Oliva, and Vilaplana, 2025) suggest that this figure is undervalued. The official statistics capture the user's participation in public prices but ignore the immense private effort that families make when, faced with a lack of public places, they must hire private services using a Service-Linked Benefit (PEVS) that does not cover the real market cost. When this “out-of-pocket” spending is included, private contributions soar to the range of 35-40%, revealing a system that is less public than it appears.
7
Final reflections
In recent years, Spain has significantly improved state financing and reduced the limbo of dependency since 2021. However, territorial inequalities, pressure on informal care, and challenges of care quality persist.
“The absence of a systematic evaluation of care quality hinders the continuous improvement of services. In addition, there are problems in human resources -low remuneration and deficiencies in training- the need for better coordination between the healthcare system and the care system. And to ensure the financial sustainability of the system to secure its long-term viability”
One of the main challenges of the care system relates to quality and sustainability. The absence of a systematic evaluation of care quality stands out, making continuous service improvement difficult. This is compounded by problems in human resources, characterised by low remuneration and deficiencies in training, as well as the need for stronger coordination between the healthcare system and the care system. Furthermore, the progressive ageing of the population necessitates ensuring the financial sustainability of the system to secure its long-term viability.
Public spending on long-term care could reach 1.8% of GDP by 2050, or up to 3% if Spain converges with the European average. The current model requires predictable financing, homogeneous access mechanisms, and a reduction in dependence on informal care. A national strategy based on evidence is necessary to ensure territorial equity and the sustainability of the system. ♦