From social welfare to public health: reforming Spain’s thermalism model in light of European best practices

Thermalism occupies a strategic position at the intersection of public health, preventive medicine, and health tourism, yet significant cross-national variation persists in how public authorities fund, regulate, and integrate balneotherapy into national health systems – with direct consequences for the competitiveness of spa destinations and the sustainability of rural economies dependent on thermal resources. This paper presents a structured comparative analysis of public funding models for thermalism in four European countries – France, Germany, Italy, and Austria – drawing on a lesson-drawing approach to comparative policy analysis structured around five dimensions: legal and regulatory frameworks, social security coverage, medical prescription criteria, multi-actor governance, and socioeconomic impacts. The study identifies three factors that consistently underpin successful institutionalisation: a consolidated scientific evidence base, clear normative frameworks governing access and quality, and effective intersectoral governance connecting health and tourism policy domains. Drawing on these findings, it analyses the structural gap between the European models and the Spanish case, where thermalism remains primarily conceived as a social welfare instrument – through the IMSERSO Social Thermalism Programme – rather than as an integrated health and tourism policy. The comparative evidence suggests that progressive integration of thermalism into Spain’s National Health System, modelled on transitional approaches such as Austria’s, is feasible and coherent with broader European trends – a direction now reinforced by a May 2026 Spanish Senate motion calling for the inclusion of balneotherapy in the common benefits package. The paper concludes with transferable policy recommendations for integrated health-tourism governance frameworks for thermal resources.