ABSTRACT
In 2018, Spain was ranked as healthiest in the world by the Bloomberg Healthiest Country Index. The Index also ranked its highly decentralized health system as third in terms of efficiency. COVID-19 is severely testing both the Spanish federal territorial model and the National Health System (NHS). During 2020, Spain was one of the worst-hit countries in the world both in terms of infections and deaths. The COVID-19 crisis has above all revealed the structural weaknesses and cyclical problems of the Spanish territorial model. From the central government to the municipalities, vertical intergovernmental coordination instruments and joint decision-making bodies were insufficient to respond to the crisis appropriately. From Catalonia to the Canary Islands, horizontal intergovernmental coordination is non-existent. During the pandemic, the tension between the constitutionally determined framework legislation of the central government and the reality of heterogeneous regional health systems was also revealed.
