When Coordination Fails, Citizens Pay the Price: Lessons from Spain’s Long-Term Care System

This blog post is based on an article published in the Journal of International and Comparative Social Policy by Jorge Hernández-Moreno.

In Spain, more than 1.5 million people rely on public support to live with dignity – people who cannot dress, eat, or move around without help. Since 2006, the state has formally recognised their right to care through the System for Autonomy and Care for Dependency (SAAD, by its Spanish acronym). Nearly two decades on, the question that should guide any honest evaluation of the system is not how much has been invested, but how well it actually works: are the different levels of government effectively coordinated? Do social services and the health system genuinely talk to each other? The answers, as our research reveals, are far more uncomfortable than official discourse tends to suggest.

A Moment of Reform – and of Reckoning

The political context makes this debate particularly urgent. In July 2025, the Spanish government approved a draft law to reform the Dependency Act – currently under parliamentary consideration – that promises to expand the catalogue of services, recognise telecare as a universal right, eliminate incompatibilities between benefits, and advance socio-sanitary coordination. It is the most ambitious reform of the system since its creation. And yet, as the annual report of the Association of Directors and Managers of Social Services published in March 2026 makes clear, the system continues to fall short: only six autonomous communities pass the performance evaluation, while the average wait to receive a benefit exceeds 341 days, with stark differences between territories – ranging from 113 days in Castilla y León to 559 in Murcia. Some 32,704 people died last year while awaiting some form of administrative processing: one every sixteen minutes.

This gap between reformist ambition and daily reality is precisely the starting point of our article published in the Journal of International and Comparative Social Policy. Our central argument is that the SAAD’s crisis is not merely financial, nor exclusively political. It is, to a significant degree, a crisis of coordination – between levels of government and between policy sectors.

A Tool to Measure What Goes Unmeasured

To address these questions, we developed the Long-Term Care Coordination Index (LTC-CoIn), a composite index designed to systematically and comparably evaluate the degree to which coordination mechanisms in long-term care systems have been developed. The index captures two analytical dimensions: intergovernmental coordination (between central government, autonomous communities, and municipalities) and intersectoral coordination (between the health and social services systems).

Each dimension is operationalised through indicators that go beyond the formal existence of legal mechanisms or administrative structures. What we measure is their degree of institutionalisation, their real operational capacity, and their practical effectiveness. The methodology combines exhaustive documentary analysis of national and regional regulation with 16 semi-structured interviews with public officials from all three levels of government and sector experts, conducted between September 2024 and July 2025.

The Diagnosis: A Structural Asymmetry

The SAAD’s overall score on the LTC-CoIn is 20 out of a possible 39 points (51.3%). But the most revealing finding is not the total figure – it’s the gap between dimensions. Intergovernmental coordination reaches 61.1% (11/18 points), while intersectoral coordination barely achieves 42.9% (9/21 points), an 18.2 percentage-point difference that constitutes the study’s central finding.

Over nearly two decades, the SAAD has built a reasonably articulated ecosystem of intergovernmental mechanisms: the Territorial Council, the Delegated Commission, the Inter-Administrative Cooperation Framework, and various technical working groups. These mechanisms are, however, subject to persistent tensions stemming from the system’s chronic underfunding, competence-related conflicts between the state and some autonomous communities, and the absence of harmonised co-payment criteria – all of which generates significant territorial inequity. As one of the public officials interviewed put it: “The Territorial Council has a very political character, which makes reaching agreements very difficult.”

It is on the intersectoral dimension, though, where the diagnosis is most troubling. Socio-sanitary integration remains, nineteen years after the approval of the Dependency Act, an unresolved structural challenge. The most critical deficits cluster around three areas: the absence of integrated information systems that would allow data exchange between health and social care professionals; the lack of standardised referral protocols between sectors; and the absence of consolidated interprofessional training programmes. The COVID-19 pandemic exposed these shortcomings with brutal clarity – the management of the crisis in residential care facilities was hampered, among other factors, by the sheer impossibility of cross-referencing data between health and social services information systems.

Dependency and Territorial Governance: An Unresolved Equation

These findings speak directly to Spain’s ongoing territorial debate. Spain does not have a single dependency system; it has seventeen. The political decision in 2006 to anchor the SAAD within the social services system – an area of exclusive regional competence – rather than within Social Security was the outcome of a complex negotiation in which employers’ organisations opposed an increase in social contributions, while regional governments and autonomist parties resisted the central state acquiring executive competences in their territory. The result was a tax-funded, intergovernmentally managed financing model that, structurally, limits the central state’s ability to offset territorial imbalances and guarantee homogeneous access to benefits.

The consequences of that institutional choice are now fully visible in the data. Percapita investment for those receiving care ranges from €3,102 in the Basque Country to €1,490 in Galicia. The proportion of people with a recognised entitlement who remain on a waiting list varies from 1.3% in Aragón to 28.6% in the Canary Islands. The reform bill under consideration establishes minimum quality standards and response times, but management will remain at the regional level. The question the legislator has yet to answer satisfactorily is: how can territorial equity be guaranteed in a system whose very institutional architecture disperses responsibility?

A Tool to Compare and to Improve

The LTC-CoIn is not intended solely as a diagnostic instrument for the Spanish case. Its architecture is designed to be replicable in any long-term care system operating within a multilevel governance context. Future comparative applications – across Spain’s own autonomous communities, or between national systems across Europe – will make it possible to identify which institutional configurations produce better coordination outcomes, and under what conditions socio-sanitary integration stops being a rhetorical aspiration and becomes an operational reality.

In a context where demographic ageing will place ever-greater pressure on care systems – Spain projects that the share of people aged 65 and over will exceed 30% of the population by around 2050, as illustrated by the INE dependency rate data by autonomous community – the capacity of states to coordinate their institutional response effectively is not merely a technical matter. It is a condition for guaranteeing rights. And measuring that capacity, rigorously and comparably, is the first step towards improving it.

Reference

Hernandez-Moreno, Jorge. 2026. “Governance of the Spanish Long-Term Care System: Measuring and Comparing the Scope of Intergovernmental and Cross-Sectoral Coordination (2006–2025).” Journal of International and Comparative Social Policy: 1–24. doi: 10.1017/ics.2026.10096.

About the Author

Jorge Hernández-Moreno is a research fellow at Institute of Public Goods and Policies, Spanish National Research Council, Madrid, Spain.