Spain's Primary Health Care (PHC) system stands as a beacon for countries striving to move towards PHC-oriented systems^1,2. Spanish PHC arose with substantial foundations from ratification of the Alma-Ata Declaration, the establishment of the speciality of Family and Community Medicine and approval of the General Health Act³. Its development over the following decades, coinciding with the decentralisation of healthcare competencies to the autonomous communities, gave rise to a wealth of experiences fostered by the need to adapt to the context.

Several strengths make Spain a leader in PHC. Namely, a solid national legislative framework enshrining universality, free access, equity, community orientation and a comprehensive range of services; a consensus-based, decentralised governance model that enables tailoring of implementation to local needs; multidisciplinary teams underpinned by solid family medicine and advanced (and yet growing) nursing roles; and advanced digital tools including the widespread use of electronic health records and a world-class, system-wide, multimorbidity-based, population health management tool. These aspects lead to in one of the lowest rates of avoidable hospital admissions in the European Union (EU). They also play a significant role in Spain having one of lowest rates of unmet needs for medical care and one of the lowest incidences of catastrophic health spending in the EU⁴.

Amidst the recognition of Spain’s PHC, it is essential to acknowledge that the system is encountering significant challenges due to the exacerbation, by the seismic impact of the COVID-19 pandemic, of chronic problems that have persisted for more than a decade^6-8. Despite overall good performance, there are signs of deterioration of access, longitudinality, coordination, PHC workforce attraction and retention capacity and citizen satisfaction with the system⁶. This requires urgent attention and concerted action across areas such as governance and financing, human resources for health and services delivery. Against this backdrop, the collaboration between the World Health Organization (WHO) Regional Office for Europe and the Spanish Ministry of Health led to the publication of a Case Study on Primary Health Care in Spain, “Primary health care transformation in Spain: current challenges and opportunities”⁸.

A comprehensive analysis was performed according to a three-phase exploratory qualitative design incorporating desk research, stakeholder engagement events, urban and rural facility visits, thematic analysis and findings synthesis. The analysis draws on valuable insights from national and regional decision-makers, scientific and patient organisations and trade unions. The case also studied documents good practices implemented by the Autonomous Communities, who were involved and enabled highlighting their strengths, innovations and challenges. Throughout the process, WHO embodied a neutral platform to bring together, foster debate and exchange ideas among the stakeholders included and channel the voices of practitioners to policymakers.

This rigorous approach resulted in crucial policy recommendations organised in four pivotal areas: governance and funding, human resources for health, services delivery and digital health.

The recommendations under governance and funding aim to enhance the prominence of PHC at all levels. These include, among others, decisively increasing spending on PHC; the establishment of a specific PHC unit in the Spanish Ministry of Health with sufficient staff and resources; strengthening governance structures in autonomous communities to ensure that the budget and capacity for action of primary care is prioritised and safeguarded; and promoting the autonomy and decision-making capacity of health centres.

Regarding the human resources for health, the recommendations focus on ensuring the attraction, retention, professional development, and prestige of the PHC workforce. These include improving the working conditions of PHC by ensuring adequate workload, job stability and flexibility; favouring continuing professional development; promoting the involvement of PHC professionals in universities and developing an academic career in PHC; gradually setting out the speciality of family and community nursing as a mandatory prerequisite for practice in PHC; or strengthening the training programme in family and community medicine by increasing the rotation time in primary healthcare^9,10. The case study also recommends streamlining workforce resource planning at the national level to align PHC workforce numbers and composition with future needs.

A third block of recommendations focuses on strengthening and advancing the foundational pillars of the service delivery model to tailor this to the new realities. These include measures aimed at fostering PHC's capacity to resolve problems by unlocking the full potential of its multidisciplinary teams, further developing and sufficiently prioritising the community orientation of PHC, and strengthening the coordination between primary care and other levels and services (importantly, social care) so PHC becomes the backbone of health-generating, integrated care at the community level¹¹.

Lastly, the study underscores the significance of embracing digital innovation and ensuring full health information system interoperability to ensure data exchange between different levels of care, social services and other community resources. These measures are essential to enhance service delivery, improving efficiency, fostering a seamless experience for healthcare providers and recipients across regions and enhancing PHC performance monitoring¹².

In conclusion, to realise the envisioned PHC system, PHC necessitates bold, coordinated actions at both national and subnational levels, using as a compass the consensus attained by the Strategic Framework for Primary and Community Care and the Action Plan for Primary and Community Care^13,14. The proposed policy recommendations are strategically aligned to fortify PHC's governance, quality, accessibility, longitudinality, coordination, integration, community orientation, and innovation.

Political commitment at all levels materialised as appropriate resources becomes the linchpin for implementing these recommendations. This requires collaborative efforts among policymakers, health professionals, communities, patients and citizens. The urgency of a collective effort to boost the Spanish PHC system is paramount, ensuring its resilience and sustained excellence in the face of evolving challenges. This study serves as a clarion call for a united commitment to fortify and uplift the Spanish PHC system, ensuring a resilient and high-performing healthcare landscape for the nation and inspiring global endeavour in primary healthcare.