History

Although there are precursors in the early years of the 20th century – the Ley de Accidentes de Trabajo (Work Accidents Act) of 1900 and the creation of the Instituto Nacional de Previsión or INP (National Institute of Social Security) in 1909 – the history of health insurance in Spain begins in 1943, shortly after the end of the Spanish Civil War (1936-39), with the founding of the Seguro Obligatorio de Enfermedad or SOE (Compulsory Insurance Against Illness) by the Falange Española, the Spanish fascist party. It was modeled on the Italian fascist health insurance system and financed by workers and employers. Like the social security system created in Germany by Bismarck in the 19th century, it covered only those who paid into it. The INP and the SOE remained under the control of the Ministry of Labor (Ministerio del Trabajo) from 1943 to 1976. By 1960, only 50 percent of the Spanish population was covered because the system was reserved for blue- and white-collar industrial workers. Public servants, members of the armed forces, and a number of other groups had separate coverage via a monthly fee withheld from their salaries. The SOE did not cover mental health care, which was provided through public and private beneficent institutions.

The Ley de la Seguridad Social (Social Security Act) of 1967 broadened coverage to include peasants and sailors, and marked the beginning of the transition from the SOE to a universal-coverage system. By 1975 three quarters of the population was covered. Following the end of the Franco dictatorship in 1975, Spain created a Ministry of Health (Ministerio de Sanidad), and the INP became INSALUD (National Institute of Health). At this point Spain had a network of hospitals and health facilities built by INP and open only to those covered by SOE, and more than a hundred hospitals operated by the diputaciones provinciales (provincial administrations) and city councils, and three dozen mental asylums operated by the diputaciones. The provincial and municipal hospitals were open to all, but operated as beneficent institutions, and suffered from significant financial problems resulting from the economic weakness of the Francoist state.

Health Care Reform

By the late 1950s, health care reform was a dire necessity because of the fragmented management of hospitals and the damage inflicted on the entire medical and health care system by the Spanish Civil War. As late as the mid-1970s, only half a dozen Spanish hospitals were being run according to international standards. The debate on health care reform began in two industrial regions (Catalonia and Asturias), and became part of a wider movement of resistance against the Franco dictatorship. After Franco’s death in 1975 the British National Health Service (the Beveridge model) inspired the main proposals for reform. The Ley de Sanidad (Health Care Act) of 1986 established universal health insurance (including mental health services) funded through the Spanish state’s general budget. All medical care is provided without charge to patients. Prescription medication is free for retired persons; all others pay 40 percent of the cost.

The 1978 Constitution reorganized Spain into a decentralized state consisting of 17 autonomous communities and two autonomous cities (the Spanish enclaves of Ceuta and Melilla in North Africa). In 1981 health care management was transferred from the central government to Catalonia, the Basque Country, and a few other autonomous communities, and by 2001 to all the rest.

Despite these reforms, the Spanish health care system remains to some extent a product of the Franco regime. Although based mainly on the Beveridge model, it contains elements of the Bismarckian model, and has retained an organizational culture based on clientelism and the protection of corporatist interests. Users of the system have absorbed its paternalistic ethos, and the expectations this generates have led to steadily increasing demand for services perceived as “free.”

The Current Spanish Health Insurance System

1) There are 18 different models of health care management, the distinctive features of which derive from questions of political economy and ideology in each autonomous community. Each model is the outcome of a specific constellation of factors that include the density of preexisting facilities, geography, and pressure brought to bear by labor unions, the Catholic Church, and professional associations, among other groups.

2) Physicians enjoy privileges unavailable to other health care professionals, in part because they are permitted to work for both public hospitals and private clinics. They are overrepresented in the public health care system, while nurses and paramedical professionals such as physical and occupational therapists are underrepresented.

3) Spain is a large and diverse country, and there are significant variations in income levels, health care costs, and health care needs across the different autonomous communities. Health care, like education and most social services, is administered by the autonomous communities but not directly financed by them. Tax revenues go to the central government, which redistributes them in ways not always proportional to needs and costs.

4) Despite universal coverage through the public health care system; there is a parallel private health insurance market and a network of private hospitals.

5) Because Spain has a declining birth rate, an aging population, and an increasing life expectancy, retirees constitute an increasingly larger proportion of public health care system users. As social policy, providing prescription medications without charge to all retired persons regardless of income level is regressive, distributing the same benefits to those with higher incomes as to those whose pensions barely cover their living expenses. In the current economic crisis, the system as a whole is unsustainable. Expert opinion favors the introduction of co-payments to reduce costs and demand for services, while public opinion resists any attempt to limit access.

Both the history of Spanish health care reform and the current state of the Spanish health care system are rich fields for research. Questions of interest include the transition from an obligatory health insurance system to one of universal access; the nature of medicalization in Spain and how it is affected by a globalized health market; the regionalization of health care and its consequences; the impact of 60 years of social insurance on cultural values; and the cultural forces shaping medical careers (Spain has one of the highest rates of feminization in all the health professions).

Gaps in research

Cultural and social studies of health insurance in Europe generally and Spain specifically are not very common. Since 1970 there has been a growing interest on the part of historians in exploring the origins of health care systems in Europe, and anthropologists have carried out local ethnographic studies. The main focus of research, however, is not in the social sciences but in the fields of health economy and public health. Most of the Spanish research is published in Spanish or Catalan and is not available in English. As a peripheral country, Spain is under-studied by comparison with the countries of the European core, and its complex administrative and political system is not well understood outside its boundaries.

Bibliography

The biannual SESPAS REPORTS provide some of the best information on the main public health problems in Spain and their implications for public health policy. A portal to official information and statistics on the Spanish health care system is located on the Ministerio de Sanidad web page. Two well-known reports analyze the main problems of the system:

Abril Martorell Report (1991, in Spanish). The Spanish government never accepted the report. A good summary of the report can be found in Wikipedia.

Vilardell Report (for the Catalan health system, 2005, in Catalan)

A very important source of information on the history of Spanish health care reform is the reports and books published by the Instituto Nacional de Previsión (1909-1977). These can now be downloaded from the INGESA web page.

Following is a selected bibliography of historical, sociological and ethnographic sources published over the past 40 years on the Spanish health care system:

Comelles, Josep M.
La razón y la sinrazón. Asistencia psiquiátrica y desarrollo del Estado en la España contemporánea.
(1988) Barcelona: PPU.

De Miguel, Jesús
The Spanish planning experience 1964-1975. Social Science and Medicine.
(1975) 8(9):451-459.

De Miguel, Jesús
La reforma sanitaria en España.
(1976) Madrid: Editorial Cambio 16.

De Miguel, Jesús
Policies and politics of the health reforms in southern European countries: a sociological critique. Social Science and Medicine
(1977) 11:379-393.

De Miguel, Jesús
La sociedad enferma. Las bases sociales de la política sanitaria española.
(1979) Madrid: Akal.

De Miguel, Jesús
Estructura del sector sanitario.
(1983) Madrid: Tecnos.

Guillén, Ana
La construcción política del sisterma sanitario español: de la postguerra a la democracia.
(2000) Madrid: Exlibris Ediciones.

Navarro, V. and Martín Zurro, A.
La atención primaria de salud en España y sus comunidades autónomas.
(2009) Barcelona: Semfyc.

Ortega, Francisco, and Fernando Lamata
La década de la reforma sanitaria.
(1998) Madrid: Exlibris Ediciones.

Sánchez Bayle, Marciano
El sistema sanitario en España. Evolución, situación actual, perspectivas y problemas.
(1996) Madrid: Los Libros de la Catarata.

Sigerist, H.E.
From Bismarck to Beveridge. Developments and trends in social security legislation. Bulletin of the History of Medicine, reprinted in Journal of Public Health Policy
(1943) 20(4): 474-496, 1999.

Josep M. Comelles M.D., Ph.D.
Laia Bailo B.A., M.Sc.
Xavier Allué M.D., Ph.D.
Susan M. DiGiacomo Ph.D.

Departament d’Antropologia, Filosofia i Treball Social
Universitat Rovira i Virgili, Tarragona, Spain