This study compared Spain’s responsiveness in healthcare and the non-healthcare systems to population mental health (MH) needs with that of all other European Union (EU) countries and the United Kingdom (UK) using data from the 2023 Headway Initiative.
Regarding responsiveness in healthcare, Spain scored 3.4 (out of 10), ranking 17th, whereas in the non-healthcare system Spain scored 4.5, ranking 25th.
Spain’s responsiveness to population MH needs remains comparatively lower than that of most European countries. Improved governance and integration of services, digitalisation, research and prevention should guide future MH policies in Spain, for which increased MH expenditure will be required.
In recent post-pandemic years, the world has faced an unprecedented mental health (MH) crisis. Results from the European Headway Initiative1 revealed substantial variation in population MH status and its underlying determinants across Europe.2 Out of 28 European countries, Spain ranked 18th (population-level MH status) and 22nd (MH determinants), respectively,1,2 indicating relatively high MH risk and overall poor population-level MH outcomes. This substantial cross-national variation was also observed in MH system responsiveness. Of concern, Spain ranked 17th and 25th in responsiveness in the health- and non-healthcare systems, respectively.3
By building on these findings2,3 and with the final goal of enhancing Spain’s responsiveness in MH through shared best practices, this study aimed to critically compare Spain’s responsiveness to population MH needs with that of all other European Union (EU) countries and the United Kingdom (UK).
MethodsThe 2023 headway mental health index initiativeThe Headway Initiative methodology, detailed elsewhere,1–3 collected data on 54 MH-related key performance indicators (KPIs) across the EU-27+UK countries. KPI scores were standardised on a 1–10 Likert scale (1=worst performance; 10=best performance), reflecting each country’s relative performance. For each variable a maximum score (10) and a minimum score (1) were assigned to the best and worst performing countries, respectively. For each KPI, each country was therefore assigned a score ranging from 1 to 10 was assigned, reflecting its performance relative to the other countries.
When the KPI comprised multiple sub-indicators (or variables), its score was calculated as the weighted average of the sub-indicator scores, using the assigned weights. Higher scores indicated better MH outcomes, such as a lower prevalence of mental disorders or suicide rates, lower alcohol use prevalence or a higher rate of adult psychiatrists. For further details on the KPIs, variables and data sources, see Table 1 (healthcare) and Table 2 (non-healthcare) of our previous study.3
Responsiveness in healthcareFifteen KPIs were evaluated across workforce (e.g. rate of adult psychiatrists), facilities (e.g., rate of hospital psychiatric beds), quality of care (e.g. rate of hospital discharges from psychiatric wards) and MH expenditure.
Responsiveness in the non-healthcare systemFifteen KPIs were assessed across workplaces (e.g., wage gap between individuals with/without mental disorders), schools (e.g., availability of day centres) and society (e.g., rate of social workers in MH).
ResultsThe full results from the 2023 Headway Mental Health Index 3.0 were reported elsewhere.2,3 Below, we provide a brief overview focused on Spain’s relative performance in its responsiveness. For further details of the results below (for instance, specific results across domains), see.3
Responsiveness in healthcareSpain ranked 17th (score=3.4), well below Sweden (10), Denmark (8.8) and Finland (8.3).
In terms of workforce, Spain ranked 25th (score=2.5), outperforming only Bulgaria (1.0), Portugal (1.9), Romania (2.0) and Slovakia (2.9) (Table 1). Spain showed the weakest performance in rate of child psychiatrists and MH nurses.
Key performance indicators of responsiveness in the health- and in the non-healthcare systems: KPI scores (S) and ranking position (R).
Regarding facilities, Spain ranked 15th (score=7.3) (Table 1), with high variation between community-based facilities (score=1.3) and inpatient services, such as psychiatric beds (score=8.1), child psychiatric beds (score=9.8) and psychiatric hospitals (score=7.5).
With regard to quality of care (QoC), Spain ranked 17th (score=3.2). Specifically, Spain’s performance in rate of MH appointments (score=4.4) and publication of psychiatric research articles (score=3.2) was comparatively poor.
Spain allocated 5% of total healthcare expenditure to MH (KPI score=3.3), slightly below the EU-27+UK average (5.4%) and less than half compared with France (13.9%), Germany (13.1%) and Sweden (10.0%).
Responsiveness in the non-healthcare systemSpain ranked 25th (score=4.5), outperforming only Slovakia (1.0), Greece (1.0) and Cyprus (3.5) (Table 1).
In terms of responsiveness in workplaces Spain ranked 19th (score=4.7) (Table 1), with particularly poor performance in employment rate (score=1.9), sick leave benefits (score=2.9), job quality (score=2.4) and availability of MH promotion programmes (3.3).
For responsiveness in schools Spain ranked 19th (score=5.1) (Table 1), while regarding responsiveness in society, Spain ranked 19th (score=4.5) (Table 1), with a particularly poor performance in rate of social workers (score=1.1) and occupational therapists (score=1.9).
Overall resultsOverall results from the 2023 Headway Initiative (MH status, its determinants and responsiveness to population MH needs) are summarised in Fig. 1. Countries in the top-right quadrant (green) showed the highest performance, whereas those in the bottom-left quadrant (red), including Spain, showed the lowest.
DiscussionMain findings
Spain’s responsiveness to population MH needs was found to remain comparatively lower than that of most European countries, particularly Northern European countries (Sweden, Finland and Denmark), and is comparable to that of mid-to-low-performing countries in Southern and Eastern Europe (Slovakia, Romania, Bulgaria, and Cyprus). Spain’s responsiveness may be strengthened through targeted MH policy changes informed by the best-performing countries, although cross-national differences in welfare systems, funding models and social structures should not be overlooked.
Responsiveness of the Spanish healthcare systemFrom a Beveridge model, the Spanish national healthcare system provides tax-funded healthcare to over 48 million people, free at the point of delivery, akin to other European countries. However, Spain faces a shortage of psychiatrists, MH nurses and psychologists, which could be mitigated by better-resourced primary care.4
Spain achieved a relatively good performance in inpatient settings, reflecting the predominance of a hospital- rather than a community-based MH model. Consistent with this, Spain’s performance in QoC was poorer (3.2) than the European average (around 5), with the low rate of community-based MH appointments pointing to the fragmentation between in- and outpatient services. The lowest percentage of surveyed Spaniards reporting unmet MH needs (1.62%) may thus raise uncomfortable questions about data quality and stigma.
Spain allocated only 5% of its total health expenditure to MH, in contrast to North-European countries, significantly above the EU27+UK average (5.4%). Greater national MH expenditure is associated with improved QoC and service user experience5 and lower suicide rates.6 Although the Lancet Commission recommended to allocate between 5% (low- and middle-income countries) and 10% (high-income countries) of total healthcare spending to MH,7 Spain has failed to meet this target.
Regretfully, investment in MH is still too often viewed as a cost rather than an investment, despite indirect medium- to long-term returns8 and benefit–cost ratios ranging from 2.3:1 to 5.7:1 globally.9 These economic gains are largely driven by reduced healthcare expenditures, improved work productivity and cost-effective, targeted prevention and intervention strategies, including school-based and parental programmes, workplace MH promotion initiatives and transdiagnostic group cognitive behavioural therapy in primary care. Reduced welfare dependency, improved family members’ MH outcomes and decreased criminal justice system costs, which are hardly captured by these analyses, may further enhance overall returns. However, the evidence of MH-related econonomic returns remains more limited for older populations and for low- and middle-income countries.10
Responsiveness of the Spanish non-healthcare systemSpain ranked only above Greece, Cyprus and Slovakia. Low employment rates and inadequate sick leave benefits for individuals with mental disorders were observed, with over two thirds of MH patients unemployed, a well-known barrier to recovery. Labour policies targeting unemployment, job insecurity and low wages should therefore be prioritised.
Spain ranked 19th in responsiveness in schools, which are considered ‘the right place at the right time’ for targeted prevention and early intervention strategies.11,12 Achieving this will require closer collaboration between schools and MH services.
Spain also performed poorly in responsiveness in society, ranking 20th, which may reflect a major unresolved issue such as stigma.
Next stepsThe Headway Initiative's results revealed Scandinavian countries to have the most responsive systems for MH, whereas Spain’s responsiveness was relatively poor. On the other hand, Spain achieved positive results in some objective MH outcomes, such as low MH-related mortality and suicide rates, which may be due to their biopsychosocial nature and may therefore reflect the influence of unmeasured third-party variables. From a service provision perspective, it would be interesting to examine Spain’s performance regarding community-based MH resources, such as patient waiting lists. This noted, while recognising relevant cross-national differences in welfare systems, funding models, social structures and cultural factors, previous literature suggests that lessons from these high-performing countries may include stronger clinical governance, integrated health and social care services, digitalisation, high-quality research and effective prevention strategies.
In terms of governance, not only is increased investment in MH required in line with the Lancet Commission recommendations,7 but also strategies to enhance staff recruitment and retention.
Incomplete integration of primary and secondary care with social services from a community-based model in Spain hinders the delivery of coordinated MH care.13
During the COVID-19 pandemic telepsychiatry had to be rapidly incorporated into routine clinical practice. However, most MH professionals in Spain still require training in digital skills13 and the low acceptability of smartphone-based apps among schizophrenia patients14 raises concerns about the digital divide.
More importantly, well-established MH risk factors could be addressed through cost-efficient school-based interventions.10,12,15 Given the ongoing child and adolescent MH crisis, now more than ever, MH prevention should be put at the top of the political agenda.
Strengths and limitationsThe Headway Initiative collected cross-national population-level data on 54 MH-related KPIs across all EU countries and the UK. Data were drawn from official, authoritative open-access datasets, such as Eurostat. The findings concerning Spain’s responsiveness were consistent with results from the 2021 and 2022 Headway Mental Health Index and were replicated in 2024, although the 2024 data are still pending further analyses.1
This study has four methodological limitations. First, national datasets vary in data quality. Second, KPIs were selected through expert consensus meetings and other experts might have chosen different indicators. Third, all variables and indicators were assumed to contribute equally to the KPI score. Caution is therefore warranted when interpreting the study findings, particularly conclusions drawn from the global scores. To address this issue, future studies should apply Data Envelopment Analysis techniques. Finally, both analytical and qualitative approaches were adopted, which, although unlikely, may have introduced some bias.
ConclusionsSpain’s responsiveness to population MH needs, both in healthcare and non-healthcare systems, was found to remain comparatively lower than that of most European countries. Evidence from the best-performing Scandinavian countries suggests that Spain should strengthen clinical governance and the integration of health and social care systems, increase MH expenditure and MH-related resources in primary care, adopt digital technologies and support high-quality, well-funded research. This said, both cross-national differences and the complexity of Spain’s healthcare system should be taken into account, particularly its decentralisation across 17 autonomous communities with distinct social and cultural contexts.
In 1736 Benjamin Franklin taught us that “an ounce of prevention is worth a pound of cure”. As discussed above,10,12 further delays in prevention-focused MH policymaking may have major public health and economic implications.
Ethical considerationsThis study was based exclusively on publicly available, aggregated population-level data, which did not involve any identifiable human participants. Accordingly, neither ethical approval nor informed consent were required.
FundingThis research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
The authors declare no conflicts of interest in relation to the study subject.
Data for this study findings came from the 2023 “Headway - Mental Health Index 3.0″, which was designed and elaborated by The European House – Ambrosetti. We are particularly grateful to Daniela Bianco (Partner, The European House - Ambrosetti and Head of Healthcare Practice, TEHA Group), Elisa Milani (“Headway” Project Coordinator and Senior Consultant, The European House – Ambrosetti), Irene Gianotto (Consultant, The European House – Ambrosetti) and Iacopo Del Panta (Analyst, The European House – Ambrosetti) for generously sharing the data.
