By Sonya Dowsett
MADRID (Reuters) - Raul Robledo's 82-year-old mother died on a stretcher in a corridor of the emergency unit of La Paz hospital in Madrid in February, after waiting nearly 48 hours for a room.
Patients were spilling out of the rooms, slumped on chairs and stretchers in the corridors, when Robledo's mother was rushed in with pain from leg ulcers.
"It's such an undignified way to die," said Robledo, a 48-year-old engineer.
The emergency wards of Spain's hospitals have borne much of the brunt of deep cuts that Spain has inflicted to its healthcare system over the past five years while the country was swept up in the region's debt crisis.
Now, even as Spain's economy is recovering, the state of the nation's leaner healthcare system is shaping up as a key issue in regional and national elections later this year.
Such is the concern that some hospital workers are also filing formal complaints in Spanish courts, asking judges to force hospitals to increase resources.
"Healthcare has become a symbolic theme for Spaniards," says Juan Diez, founder of the Sociological Investigation Centre (CIS), a closely-watched polling agency. "People are tired of seeing cuts made where it affects them personally."
Spain hasn't been alone in taking a scalpel to its healthcare system.
Across southern Europe, cash-strapped governments have cut national healthcare costs – in most cases the biggest part of their welfare states, after pensions – in an effort to curb public spending during the euro zone debt crisis.
Spain still offers universal health care. And government officials say spending cuts have focused less on services than on pharmaceutical spending.
Yet in hospitals around the country, doctors and nurses say they are struggling to cope with reduced funds for staff and materials.
And even though Spaniards still give their healthcare system a high rating, the number of people who say hospital care has worsened has tripled since 2009, according to CIS.
Thousands of white-coated doctors and nurses, dubbed "the white tide", have taken to the streets.
Vying parties in the upcoming elections are taking up the issue in their campaigns. The ruling People's Party has launched a campaign in Madrid under the slogan of "The best healthcare" showing smiling people outside hospitals and clinics.
Far-left upstart Podemos and centre-right newcomer Ciudadanos are campaigning over health too – a strategy aimed at drawing the vote of older people in what is one of Europe's fastest-ageing countries.
Podemos, for example, organized a demonstration outside hospitals in February under the slogan "Spending cuts shorten lives".
Spain's national healthcare spending was cut by a total of 13.6 percent, or nearly 10 billion euros, from 2009 to 2013, Treasury Ministry figures show. That is one of the biggest reductions in the European Union.
The government defends its record. Agustin Rivero, a senior health ministry official who oversees pharmaceutical spending, says the bulk of savings nationwide – 4.5 billion euros of the 7 billion announced since 2012 – has been to savings in medicine spending.
Spain now requires a greater share of drug costs be shouldered by patients and has ordered pharmacies and hospitals to use more generic drugs.
He said that despite popular belief, the number of doctors and nurses working had fallen minimally at a national level.
"We have a health system that is the envy of the world," said Rivero. "But there is a limit on what we can spend."
Madrid's regional government, run by the ruling People's Party, said La Paz and other hospitals in the region had not suffered cuts. It says overcrowding this year was the result of a particularly harsh flu season.
Hospital workers say, however, that other areas of belt-tightening have trickled down to emergency rooms. Waiting lists for an operation have grown by 45 percent nationally from 2010 to 2014 and by 52 percent in the Madrid region.
One of the reasons, says Cristobal Lopez, head of the Ear, Nose and Throat department at Puerto del Hierro hospital in Madrid, is that doctors and nurses used to work extra hours for more pay in order to get through operations. Now, hospital management is loath to continue the overtime policy.
Nurses and emergency-room doctors say patients are increasingly turning to emergency wards when they have to wait too long to get an appointment with a specialist.
"Because of cuts and insufficient investment in primary health care, the first port of call is the emergency ward," said Ignacio Aguado, a Ciudadanos party candidate running for Madrid local government.
Faced with the extra burden, some hospital workers have been writing official complaints to the nation's courts. In the complaints, three of which were seen by Reuters, nurses said the ratio of nurses to patients had fallen below official national health guidelines, putting patients' health at risk.
In one complaint, nurses from the La Paz hospital reported to courts that on January 12, 345 patients were registered in the La Paz emergency wards with 96 beds. The nurses asked the court to take measures to improve conditions. This could involve requiring the hospital to hire more staff and open more beds. The court has not yet responded.
Robledo, the engineer, says the experience of his mother dying in an emergency ward surrounded by other patients after a long wait for a room that never materialized has deeply affected him and will influence his vote.
"There are basic services that the state should safeguard," he said.
(Additional reporting by Rodrigo de Miguel; Editing by Alessandra Galloni and Peter Graff)