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Health Care and Government Policy

Laurinda Abreu

The roots of the health reform in Spain

Enrique Perdiguero-Gil et Josep M. Comelles


The aim of this article is to analyse the roots of the Spanish health reform which took place once the dictator, General Franco, had died in 1975. After contextualising the place of Spain in the development of Western health systems, we assess three key elements and their influence on the medicalisation of Spanish society. The first is the economic, social and cultural impact of the introduction of Compulsory Health Insurance (Seguro Obligatorio de Enfermedad, SOE), which came into force in 1944 and was later replaced by Social Security (Seguridad Social) in 1967. Secondly, we describe some of the keys to a clearer understanding of the predominance of the hospital in the health system, which was consolidated by the General Health Law passed in 1986, in spite of its emphasis on community health care. Thirdly, we consider the problem of healthcare access in rural areas in the 1940s-1960s, when the network of local doctors and the SOE coexisted.

Entrées d'index

Note de l’auteur

This study was carried out within the framework of the research projects entitled De la propaganda sanitaria a la educación para la salud. Ideología, discursos y saberes en la España de Franco 1939-1975’ [‘From healthcare propaganda to education for health. Ideology, discourses and knowledge in Franco’s Spain 1939-1975’], funded by the Ministerio de Economía y Competitividad (HAR2012-34588), and ‘Reforma sanitaria y promoción de la salud en el tardofranquismo y la transición democrática: nuevas culturas de la salud, la enfermedad y la atención’ [‘Healthcare reform and promotion of health during the late Franco regime and the transition to democracy: new cultures of health, sickness and care’], funded by the Ministerio de Economía y Competitividad and the European Regional Development Fund (HAR2015-64150-C2-1-P).

Texte intégral


  • 1 The 1978 Constitution recognises the right of citizens to health protection and grants the public a (...)

1In Spain, the concept of health reform (reforma sanitaria) is usually applied, colloquially and in the mass media, to a set of proposals, manifestos and political actions which appeared after the mid-1960s. The health system reform in its widest sense began with the discussions among health professionals and politicians on the drafting and implementation of the Social Security Framework Law (Ley de Bases de la Seguridad Social) of 1963, the Social Security Law (Ley de Seguridad Social) of 1967 and the General Health Law (Ley General de Sanidad, LGS) of 1986. The LGS was based on Article 43 of the democratic Constitution of 19781 and was widely debated by politicians, health professionals, social movements and trade unions. Indeed, the health system reform process is often understood as being restricted precisely to these debates surrounding the LGS. The law established a universal right to health for the first time in Spain. Health care was based on a highly decentralised – pseudo-federal – model (Lamata Cotanda, 2003; 2011) as a result both of the new organisation of the Spanish state (divided into autonomous regions) and of the significant geographical differences in existing care resources. Some regions, such as the Basque Country, Asturias and Catalunya, already enjoyed an extensive healthcare system, while in others both private and public healthcare resources were scarce. The substantial differences between the healthcare system before 1965 and after 1986 meant the reform was considered a ‘success’ (Nadal i Caparà, 2016), especially by the Partido Socialista Obrero Español (PSOE), the party in power when the LGS was passed.

2The public healthcare system was perhaps the most significant achievement of the transition to democracy that followed the death of Franco, as significant as the development of the road and railway infrastructure. Indeed, in the results of present-day surveys on social issues, the health system does not tend to figure as a main concern (Centro de Investigaciones Sociológicas, 2018: 4). The system is believed – and probably rightly so – to meet the needs of the population, although health cuts in recent years have raised concerns regarding waiting lists and the privatisation of health facilities in some regions. The fact that the public healthcare system is not usually at the forefront of political debate has in all likelihood led historians of the Transition to ignore it.

3A critical historical approach to the health reform today requires a detailed description of its limits at both state and local (regional and municipal) levels. The Constitution of 1978 established a strongly regionalised political model. Healthcare and public health activities became the responsibility of the various regions (Comunidades Autónomas), while the municipalities were entrusted with the organisation of most of the remaining social services. The fact that the 17 regions (into which Spanish territory was now divided) and the more than 8,000 municipal areas approached health system reform from different perspectives is a factor that must be considered when assessing its successes and failures.

4Overall state expenditure on health since 1980 has ranged between 5% and 7% of GDP (Pons Pons and Vilar Rodríguez, 2014: 315). Currently, hospital and specialist care accounts for more than 60% of the total and between 13% and 17% is spent on primary care. The remaining funds are reserved for pharmaceutical costs (slightly over 20%), prevention and administration (Fundación Gaspar Casal, 2017). Given the political, historical, economic, social, cultural, demographic and geographical variables, regional diversity is of huge importance and means that satisfaction with the healthcare system varies widely according to the region. In general terms, health care throughout Spain centres on hospitals, which have dominated the discourse of reform. The significance of the hospital is crucial in decision-making related to the demand for treatment, preventive medicine, health promotion and, more broadly, community medicine (Comelles et al., 2017). The healthcare system is centred, above all, on illness.

  • 2 To date, there has been little research on the history of health system reform (Navarro and Elola, (...)

5For the generations of the transition to democracy, studying and contextualising the health reform requires a review of what is usually termed the ‘myth of the Transition’.2 This expression is commonly used to describe the narrative that tends to hide or minimise the huge concessions made at the end of the 1970s, which kept intact many of the structures of Franco’s ‘New State’, built after the unification in 1937 of those political parties that supported the military uprising (Gallego, 2008). It was difficult for researchers who lived through the dictatorship and those involved in the anti-Francoist struggle to accept these compromises.

  • 3 Within Francoism there were, of course, ‘reformers’ who sought to change some areas of government a (...)

6Presenting the health system reform as a process confined to a particular period (1963-1986) is an established trend in the published literature. It is the consequence of an approach based on a series of publications, pronouncements and proposals that were issued in the context of the economic policy changes of the Regime and the political activities of the anti-Francoist movement. Francoism is considered, in this approach, to have been monolithic and ultraconservative, a parenthesis between the democratic Second Republic and the Transition. However, Francoism was not monolithic – different factions were involved in an ongoing power struggle – and not all Francoists, including some members of the upper echelons of the Regime, were fascist or reactionary.3 Furthermore, we cannot ignore the fact that between 1937 and 1978 Francoism defined itself as a movement, an alternative to the liberal democratic state represented by the Second Republic. Its vocation was to reform, and its discourse was fascist and populist. In some policy areas, particularly health and social welfare, reforms (often counter-reforms) quickly followed the end of the war as part of the ‘fascistisation’ of the State. As early as the 1940s, there were debates on the healthcare system and public health activities, and they became even more frequent in the following decade when Spain joined the technical agencies of the United Nations.

7In this article, we will describe a series of changes that occurred after 1939 under the new regime and which help to highlight and clarify the main pillars of the health reform. We will assess three key elements and their influence on the medicalisation of Spanish society. The first is the economic, social and cultural impact of the introduction of Compulsory Health Insurance (Seguro Obligatorio de Enfermedad, SOE), which came into force in 1944 and was later replaced by Social Security (Seguridad Social) in 1967. Secondly, we will describe some of the factors that help explain the predominance of the hospital in the health system, which was consolidated by the LGS (in spite of its emphasis on community health care). The third issue is the problem of access to health care, especially in rural areas, in the 1950s-1970s, when the network of local doctors and the SOE coexisted. In the epilogue we will briefly mention the proposals that were put forward in the first half of the 1970s and the official initiatives of reform.

What reform of what healthcare system?

  • 4 To avoid the inclusion of a very large bibliography in the article, we elude bibliographical refere (...)

8In order to understand the Spanish case, it is important to trace the development of healthcare systems in the western world in a medium-term perspective since the end of the eighteenth century4.

9In classic studies on the concept of ‘medicalisation’ (Busfield, 2017), such authors as Michel Foucault (1977) emphasised how healthcare systems soon became a focus of political action in the early stages of development of modern states. Since then, there has been a wide range of organisational models within nation-states. Spain is a relatively unusual case given that the divergences are related to differences in political culture and variations in the implantation of a capitalist economy. According to some French theorists (Castel, 1995; Ewald, 1996) political action in favour of the people’s health was closely linked to the collateral effects of capitalism, which forced the state to intervene as regulator, in spite of the obvious contradictions with liberal principles. In northern Europe and North America, health and illness management was based on substantially decentralised solutions, while in France and Italy the tendency was towards centralisation.

  • 5 Poor Law Amendment Act, known as the New Poor Law.
  • 6 The regulation for its implementation was published 14 March 1852.

10Regulatory measures were set out in laws on charitable organisations such as the British Poor Law (1834)5 or the Spanish Ley de Beneficencia (Charitable Law) (1849);6 in criteria for the regulation of health professions and medical education; and in general criteria designed to distinguish between hospitals and hospices. Although these measures were common in the West after the second half of the eighteenth century, the work of hospitals was only standardised at the turn of the twentieth century, in part as a consequence of the reorganisation of German hospitals in response to the social security reform implemented by Bismarck. However, hospital reform was primarily based on the Flexner Report (1910) in North America, which was designed to overcome the chaos in US medical training and to adapt hospitals to the generalised introduction of private health insurance The US hospital model has been the main influence on hospital organisation at a global level, especially since World War II, not least in Spain (Salmón et al., 1990). Because of its multiple educational, research, diagnosis and treatment functions, the German-North American model put the university teaching hospital at the top of the healthcare pyramid. However, economic, social, political and cultural factors determined that the development of the hospital model did not follow the same timeline in different countries or even within individual countries. These variations are linked to historical contexts (Comelles et al., 2017) and in particular to the varying coverage of public and private insurance schemes since the end of the nineteenth century. Spain is no exception (Pons Pons and Vilar Rodríguez, 2014).

  • 7 The first phase of the medicalisation process can be considered a Late Medieval phenomenon, at leas (...)

11The regulatory processes to which we have referred met the aims of groups of health professionals and institutions, as part of what we have defined as the ‘second phase’ of the medicalisation process (from the eighteenth century to the second half of the twentieth).7 In this phase, it was scientific-medical criteria with the support of international organisations that determined what health systems should offer society. It was suggested that they propose general criteria for coordination between the health activities of the state and those of local corporations. On the whole, in the western world, the aim of these directives was universal health coverage, either public or private, although by the mid-twentieth century there was a reassessment of these ideas (Gorsky and Sirrs, 2018).

12In fact, the nation-states took over responsibility for health care, which in the Late Middle Ages and the Early Modern period had depended on local authorities. Access to health care at the local level was a reality before the nineteenth century in all Europe, given the availability of doctors, surgeons and municipal hospitals even in small towns, although the number of beds was limited in villages. This healthcare provision encouraged links between citizen and community. The town councils and the governing boards of the care institutions drew up the criteria to determine who was entitled to these services: vagabonds, new arrivals in the town, and the poor of the community who could not fend for themselves. From the end of the eighteenth century, it gradually became the duty of the state, not the municipality, to apply medical, social and cultural criteria to determine which individuals were entitled to care and which conditions should be treated. The state also took over responsibility for providing the funds necessary to sustain the system.

13To the extent that the funding of these services is an element in the advance of capitalism, many of the models available to us were first developed in those countries most closely associated with that economic system, such as the German states, the United Kingdom and the United States. Their health systems have been considered the ‘gold standard’ against which to examine the logic of those countries and regions regarded as ‘peripheral’, while ignoring their diversity both in relation to the ‘central’ states and within their own borders. The evolution of the health systems of peripheral countries, insofar as they differ from those of the central states, is considered a product of economic underdevelopment and the fragility of their democratic systems.

14Spain is obviously a case of a peripheral country. Although the Constitution of 1812 was the third liberal constitution worldwide, after those of the United States and France, and the first Ley de Beneficencia was passed in 1822, the political and financial weakness of the state virtually precluded its implementation. Therefore, the healthcare model bequeathed by the Antiguo Régimen remained in the hands of the non-democratic local administrations, which endured serious budgetary difficulties. Great swathes of the country remained isolated and economically underdeveloped. After 1839, professional groups were allowed to set up associations seeking to provide mutual assistance in cases of natural disasters or disease, which led to the organisation of friendly societies (Pons Pons and Vilar Rodríguez, 2014: 23-79).

  • 8 The Mancomunitat de Catalunya was an institution that provided a certain degree of autonomy for Cat (...)

15At a later stage, private health insurance emerged, although its development was extremely slow in all but the more industrialised areas. Not until the twentieth century did legislation on social protection begin to appear (Ministerio de Trabajo y Seguridad Social, 1990). The Mancomunitat de Catalunya,8 between 1915 and 1925, and the Second Republic, after 1931, began to seek new models for the organisation of health care. Some Republican projects were only implemented during the Civil War, on a restricted scale, in those areas that remained loyal to the legitimate government. Although projects to broaden health coverage and social protection were discussed before the war, there was no way to implement a public health insurance scheme (Jiménez Lucena, 1997; Pons Pons and Vilar Rodríguez, 2014: 79-96). Francoism, obviously, represented a new stage.

Health care during Francoism: between rupture and continuity

16At an assembly convened to draft the agenda for social and health measures for the new Spain, the director of the Hospital Clínico in Barcelona, Vicente Carulla Riera (1896-1971), who was a specialist and later a professor of physical therapy, raised the main health problems which the new regime would need to cope with once the Civil War had ended (Carulla, 1939). His diagnosis and proposals, as a doctor loyal to the new regime, are useful for understanding the context and the solutions which were put forward and implemented.

  • 9 The data used by Carulla came from de la Quintana and Aznar, although he did not cite specific work (...)

17Carulla felt that the main issues facing the Spanish population in the post-war era would be unemployment and what he described as the ‘disease of poverty’ (Carulla, 1939: 69), in which physical suffering went hand in hand with the abject condition of the poor. He provided a series of data to demonstrate the vulnerability of the Spanish population in terms of high mortality rates, due basically to poverty.9 The worst living conditions were those endured by the largest sector of the population in rural areas where, according to the ideology of the Regime, they preserved the purity of the traditions of the ‘national soul’. In these rural areas doctors were few and far between, and extreme poverty prevented any solution which might provide reasonable health care.

18Given these circumstances, Carulla (1939: 74) believed that ‘social’ health care could only be organised through a collectivised illness insurance which would cover 60% of the Spanish population. Charitable health care would cover another 15%, and the remaining 25%, which he labels ‘the powerful’, would rely on private medicine. He also underlined the important role of preventive medicine in reducing premature mortality and healthcare expenditure. To strengthen his proposal, he carried out an extensive review of social security systems in other countries and a synthesis of the healthcare facilities that existed in Spain in 1939, including state resources and provincial and local charities. The author included his arguments in the debate on social reform (inspired by Bismarck’s principles, to which he referred explicitly), the bases of which had been discussed in Spain since the creation of the Comisión de Reformas Sociales (Commission for Social Reform) in 1883 (Pons Pons and Silvestre Rodríguez, 2011). Carulla thus believed that the social security route was the only possible solution to the shortcomings of post-war health care. Nevertheless, there did remain a role for charities, which Francoism was keen to encourage.

  • 10 Under Franco’s dictatorship, the term ‘Victory’ acquired an ideological, symbolic and practical mea (...)
  • 11 In 1934 the Falange and the Juntas de Ofensiva Nacional Sindicalista merged. In 1937, at the height (...)

19The reconstruction of provincial charities (Palacio Lis and Ruiz Rodrigo, 1993) following the ‘Victory’10 was not a reform, but rather the perpetuation of the ‘poor man’s medicine’ which Carulla had condemned. By maintaining them, the Regime was able to offer a role to some of its factions, including the clergy and above all the various religious orders. Furthermore, the continuance of charitable works also proved useful for the corporate interests of some medical sectors. Nevertheless, the real novelty in the management of health and disease appeared with the implementation of the SOE, under the auspices of the fascist and national-syndicalist faction of the Regime, the Falange Española Tradicionalista y de las JONS.11 The initial hegemony of these sectors of the new regime led to a process of fascistisation based on the notions of social action defended by these organisations. The main activities centred on Social Aid, a charitable foster-care institution; the decentralised social action of the Women’s Section (Sección Femenina) of the FET y de las JONS; and, above all, the creation of the SOE, a centralised healthcare system in the hands of the state (Girón de Velasco, 1953).

20The SOE, regulated by the law of 14 December 1942, was presented by Franco’s regime as the main achievement of its social policy, although it did not come into effect until 1944. Based on the models of Nazi Germany and Fascist Italy, the SOE adopted the features of a Bismarck-like system, in which compulsory payments were limited to employers and workers, and the state made only a minor contribution. It was restricted to low-income workers (both blue and white collar) and excluded the significant section of the Spanish population that was employed in agriculture, mainly as wage earners. In the early years the benefits were limited to primary care, drugs, hospitalisation for surgical procedures, including child delivery care, and sickness benefits. The system later added specialised health care and internal medicine care in hospitals (De Miguel, 1979: 63-115; Pons Pons and Vilar Rodríguez, 2014: 105-137).

  • 12 This system was known as iguala.

21Until 1944, the population accessed health care through five different gateways: charities in urban areas (for the destitute and low-income workers); doctors hired by towns and villages for the health care of the poor; payment of a regular family fee to the local doctor, traditional in the rural milieu;12 the mutual system in industrialised urban areas; and private medicine for the affluent. The last two allowed for a free choice of doctor. The implementation of the SOE changed this panorama for a part of the population. We need to bear in mind that in 1954, ten years after the system was launched, only 30% of the population was covered. It was not until the mid-1960s that this figure reached 50% (Pons Pons and Vilar Rodríguez, 2014: 127).

22The implementation of the SOE was hindered by several obstacles: the high financial demands without regular state contributions, the lack of healthcare premises and the resistance of those groups historically opposed to any social insurance, mainly medical doctors. The debate was intense and sometimes took place in the public arena. Although the general press was censored, the huge disagreements on the way the SOE was implemented were aired in several publications, including official ones.

23The General Health Board, in charge of the fight against infant mortality and epidemics, did not participate in the design of the SOE. In 1944 a General Health Law was passed to update the previous one of 1855. The law established the basis of the various national health services and encouraged harmonisation both among them and with the educational and research systems. Nevertheless, there was no coordination, and the Spanish health sector had dozens of organisations each with its own political agenda, frequently resulting in the duplication of services. From the beginning of the SOE, the Head of the General Health Board, the military officer José Alberto Palanca (1888-1973), opposed the Ministry of Labour’s plans for the development of the healthcare system. Although the disagreement was mainly based on the in-fighting among the different political sectors supporting Franco, he denounced the neglect of preventive medicine in favour of the growing healthcare structures, and the lack of coordination (Palanca, 1958: 58, 116-117; 1965: 201-211; Noguera, 1962). According to Palanca, from the outset the sickness insurance scheme carried the burden of the hegemony of political interests over technical criteria.

  • 13 ABC, 26 June 1949, 16.

24Five years after the setting-up of the new healthcare system, statements by the Minister of Labour in the newspapers called for ‘dialectic serenity’ in the discussions on the development of the SOE.13

25Low-income workers were required to pay a subscription, as in a mutual insurance scheme, for primary care, medicines and sickness benefits. Primary care under the SOE was delivered by doctors hired by the National Welfare Institute. At the end of 1947, there were 25,000 doctors in Spain, 17,000 working for the SOE mainly on a part-time basis (Pons Pons and Vilar Rodríguez, 2014: 114). They were required to care for a number of insured workers and their families, but their salaries were calculated on the basis of the number of medical cards, one for each worker, and failed to take into account the actual number of beneficiaries in an age when families were large. This situation and the increase in the population covered by the system, due to the extension of the income bracket for compulsory enrolment, caused constant complaints from doctors. They spent two hours per day caring for patients with conditions that did not prevent them from visiting the doctor in their surgeries or in the SOE’s facilities, which were scarce in the early years. There was no time for clinical examination and this feature of health care did not improve over the years (Bravo et al., 1979: 134-167). Doctors visited patients at home for more serious sicknesses, and hospitals were only for surgical operations and childbirth. Physicians had the freedom to prescribe medicines without limit (Bravo et al., 1979: 104-133; De Miguel, 1979: 152-159).

  • 14 See the discourse of the Ministry of Labour: La Vanguardia Española, 13 July 1950, 5.

26The resort to prescriptions was the SOE’s most long-lasting legacy in the construction of a specific manner of medicalisation in Spain, which placed drugs at the centre of health care. Medicines were free for all beneficiaries, although the number of weeks they were entitled to health care was limited, especially for the families of those in the scheme (26 weeks for enrolled workers, 13 for their families). Beneficiaries had previously only enjoyed limited access to drugs, and now sought to recover their contributions by asking for prescriptions. Doctors, with no time to examine patients, used medicines as the only way to avoid dissatisfaction and tension. The constant rise in expenditure on medicines was a concern for SOE managers from the very beginning (Fernández Turégano, 1958 [1948]: 31-33).14 In 1946, it represented 36% of the total budget, but reached 48.72% in 1952 (Pons Pons and Vilar Rodríguez, 2014: 132). The causes of this rising pharmaceutical expenditure, as expressed by the different players involved in the management of the SOE, were the abuse of prescriptions and the introduction of new drugs, such as antibiotics (Comelles, 2004; Lobo Aleu, 1979; Pons Pons and Vilar Rodríguez, 2014: 132). However, we believe there is a need to clarify the reasons for the word ‘abuse’. There was of course fraudulent prescribing by doctors, and also cheating by patients (Lanzán Orellana, 1945; García Guerras, 1946). The press published news items on this topic, with comments highlighting the dangers of this behaviour for the sustainability of the system. However, the main reason for this ‘abuse’ was probably that prescriptions were a substitute for proper health care (Bravo et al., 1979: 124-127).

27In order to control pharmaceutical expenditure, some voices from the National Welfare Institute proposed restricting prescriptions to serious conditions or a system of co-payment. Finally, the approach chosen was to finance only a limited number of drugs. In 1951, a committee drew up the list of drugs to be prescribed with funding from the SOE, but the reform was not implemented until 1953. The advisers to the Minister of Labour had serious doubts about the restriction. It went against the Regime’s propaganda on its commitment to ‘social justice’. To legitimise the controls, a poll was held in workplaces in which employees had to choose between two options. A ‘yes’ vote would mean they accepted the list, which included antibiotics and all the ‘modern drugs’ – the main argument of the Regime. A ‘no’ vote would retain the status quo, but exclude the new drugs from free prescriptions. Predictably, the results of the ballot were never published, but official sources claimed that the great majority of workers supported the list (Redondo Rincón and González Bueno, 2013). The reform was unsuccessful, and pharmaceutical expenditure continued to rise over the years.

28A decade after its implementation, the SOE faced serious problems and the manner in which disease was managed in some sectors of the working class changed dramatically. Below, we set out some examples of opinions of doctors and the population on these changes.

  • 15 See also the article Encuesta sobre la seguridad social. Contesta el Doctor Don José Espriu Castell (...)

29We need to take into account the fact that a great number of complaints came from doctors, especially when the number of workers affiliated to the sickness insurance scheme grew significantly. Their demands included pay rises and changes to the recruitment system. Doctors complained about the bureaucracy of the system and the transformation of physicians into salaried subordinates of managers who acted according to political agendas with scant regard for suitable health care (García Tornel, 1949; Cianófilo, 1957; De Gispert, 1976: 163-175).15 Dispensing chemists also demanded agreements under which they would be able to maintain their income. These questions deserve special attention that goes beyond the scope of this article but it is fair to say that there was widespread dissatisfaction with the healthcare system.

  • 16 We can see this kind of criticism in the article Sobre el personal sanitario y sus problemas y nece (...)

30The criticism of the way health care was delivered by the SOE emphasised an important problem in the doctor-patient relationship: the choice of doctor. The system intended to provide one doctor for every insured worker and his family, depending on their place of residence. Although there was some room to change the designated doctor, and this became more clearly regulated over the years, the choice was still limited to those available in the area. Neither beneficiaries nor doctors had any previous connection and were perfect strangers on the first occasion they met at the surgery. This was one of the main criticisms raised by the official associations of physicians (Villar Aymerich, 1950; Mussons Viladot, 1950; Jusué González, 1950). Although the heads of these associations were appointed by the authorities, which explains the mildness of their opposition to the new system, doctors were able to express their complaints through sections organised by those hired by the SOE (De Soroa, 1962). As mentioned above, in primary health care there was simply no time for doctors to do anything more than ask a couple of questions about the patient’s condition and to write a prescription based on a rough diagnosis. The situation was exacerbated from the doctors’ point of view by the lack of trust between physicians and patients, which hindered therapeutic efficacy. Doctors highlighted the people’s demands for medicines and had no choice but to issue ‘indulgence prescriptions’ to avoid arguments with their patients, who, in their view, were supported by the SOE inspectors. This may be true because, as we have seen, the Minister of Labour considered the generous policy of prescriptions as a cornerstone of the health insurance scheme. These concerns were stronger among Catalan doctors. From 1949 to 1954, doctors working for the SOE in Barcelona published a monthly bulletin, Horizonte, in which they voiced their criticism of the way the SOE was being implemented.16

  • 17 These cooperatives, known as igualatorios colegiales, developed out of similar ones which had been (...)
  • 18 On his role as a medical populariser, see Comelles (2015).
  • 19 The model spread throughout Spain and gave rise to ASISA (Asistencia Sanitaria Interprovincial de S (...)

31The shortcomings of the SOE encouraged an upsurge of private healthcare schemes in the context of a new medical market. This development was fragmentary and regulated from 1954 onwards by a new insurance law. It was particularly noticeable in Catalunya and the Basque Country (Pons Pons and Vilar Rodríguez, 2014: 167-180), where even before the war mutualism and private healthcare insurance had been widespread (Pons Pons and Vilar Rodríguez, 2014: 42-79). An important initiative from the viewpoint of doctors’ rejection of SOE medical practice was the foundation of doctors’ cooperatives for the provision and management of healthcare services, coordinated by the official medical associations.17 They offered health care for a flat fee in order to provide an affordable alternative to the SOE. This kind of enterprise was based on the model of the Igualatorio Quirúrgico y de Especialidades, founded in Vizcaya in 1934 and inspired by a French medical cooperative. One of the more significant of these cooperatives was the Asistencia Médica Colegial (Espriu Castelló, 1986; Roda, 1996), 18 an initiative of Josep Espriu Castelló (1914-2002), which was set up in Catalunya and began work in 1960.19

  • 20 The non-scientific journals for medical doctors frequently published complaints about the organisat (...)

32The topic of the free choice of doctor reappeared as a bone of contention when, from 1963 to 1966, the Francoist Cortes debated the new Social Security system. In the 1960s, in a political context that was more tolerant of dissidence, the official medical associations opposed the maintenance of the system used to assign doctors and also specialists, who had increasingly entered the system during the 1950s.20

  • 21 Seguro de enfermedad. Las prestaciones graciables, ABC, 11 January 1956, 29. Seguridad obligatorio (...)
  • 22 Egea, L. (1964). El teléfono inútil, La Vanguardia Española, 5 April, 31. Querol, J. (1965). Proble (...)

33Other aspects of the SOE also became targets for complaints. In 1956, ABC, the main newspaper published in Madrid, used letters from readers on health care and other benefits of the system as a formula to explain how it worked. The letters were in all likelihood fictitious, but the range of problems covered gives us an idea of the conflicts that arose: the unpopularity of the list of subsidised medicines, the insufficient period of healthcare entitlement, the difficulties caused by the system of referral among services (i.e. primary care and diagnosis services), the problems with specialist care, the totally inadequate emergency services, the restrictions on inpatient visiting, and the unpleasant behaviour of auxiliary staff, among others.21 At the end of the period under consideration the Barcelona newspaper La Vanguardia Española published bitter complaints about the emergency services and healthcare premises, especially the ambulatorios, the outpatient departments set up under the SOE.22 Some of them worked well but the great majority were crowded with noisy waiting rooms and were absolutely overwhelmed by the number of patients.

  • 23 See, for example: Los ‘seguros sociales’ del franquismo: un latrocinio a cara descubierta, Mundo Ob (...)

34Little is known of workers’ opinions of the SOE (Noguera et al., 1962). The corporate organisation of doctors in colegios (medical associations) offered them a level of influence that wage earners could not match. In the absence of free trade unions, their complaints about the workings of the SOE had no outlet, and membership of the ‘vertical’ unions based on productive sectors was mandatory for both employers and employees. Censorship prevented any criticism from SOE members in the press. As yet, there has been no analysis of the clandestine workers’ press and we only have a few references on which to draw.23

  • 24 It was eventually published without censorship in 1976 (Candel, 1976).

35We do have the interesting impressionistic picture drawn by Francisco Candel in his book on the working-class way of life – written in 1966, first published in 1968 and promptly banned by the censors24 – which devoted a chapter to the inadequacies of the SOE. The author, who considered the SOE a system in urgent need of assistance, used narratives of therapeutic pathways in order to describe its defects. In his view, doctors were against the reform of the system while patients ‘grumbled […], as they always grumbled in the waiting rooms of the outpatient departments […]’ (Candel, 1968: 160). He humorously described an episode of a housewife asking for prescriptions for every member of her family (Candel, 1968: 164-165).

36Felip Solé Sabarís (1915-2005), a medical doctor, later a politician and a committed opponent of the dictatorship, used Candel’s arguments to express his pessimistic assessment of the SOE. His notes to the Spanish translation of Le grand tournant de la médecine libérale by Henri Hatzfeld (Solé Sabarís, 1965) included a lengthy appraisal of the state of the Spanish health system.

37As a counterpoint, we have the report on the social situation of Spain published in 1966 by an independent foundation, FOESSA, financed by a Church organisation. The report included the data from a survey of a stratified and randomised sample of 2,500 homes. In every household, the head of the family and the housewife were interviewed. The report shows the great regional differences in the implementation of the system. Generally speaking the SOE was assessed positively by men and women, especially by those insured under the scheme. The more privileged social classes, who were outside the system, were more negative in their appraisal. Housewives who had requested a home call had the most positive views. There was a clearly favourable assessment of health premises and professionals and a negative verdict on the bureaucratic organisation of the SOE. A significant feature was the low level of care for pregnant women and especially children. Only a third of housewives overall – a quarter in rural areas – went to the doctor for their children’s illnesses (Fundación FOESSA, 1966: 138-148).

38From an economic point of view, the SOE was unsustainable (Vilar-Rodríguez and Pons-Pons, 2013: 281-285). When the Regime abandoned the autarchic system and embraced liberal economics, a major reform was needed. A new Social Security system, including health care, was finally implemented after long discussion on 1 January 1967. The new regulations were designed to unify the different types of subscription to the various social insurances, and to extend cover to the entire working population. However, universal cover was ruled out for economic reasons. Funding continued to depend on the contributions of employers and employees, with minimal state support (in 1970 only 1.32 % of public expenditure went to health). The system had serious defects including the de facto continuation of different terms of cover according to the economic sector. It had to be amended several times in the following years, although it still failed to achieve the level of coverage of countries in the European zone (Pons Pons and Vilar Rodríguez, 2014: 218-232).

39There is no doubt that the SOE, known colloquially as ‘el seguro’ (‘the insurance’) caused a profound change in how people dealt with health and illness. The way they made decisions on disease matters was modified by the incorporation of new values, meanings and ideas which developed from the SOE and how it operated. In the early stages, access to medical care and free medicines, a key feature of the Regime’s propaganda, led to a huge growth in healthcare demand. The more prescient doctors warned of the loss of care quality and even of the ethical dilemmas that would arise under the SOE. Nevertheless, access to SOE health care for ever broader sectors of the population in Spain reinforced a medical culture rooted firmly in the idea of the almost miraculous effects of industrial medicines (Comelles, 2004). Free prescriptions undermined the argument still present in the work of Carulla (1939: 73) in relation to the lower costs of such traditional care options as folk medicine. As highlighted in research into medical pluralism (Perdiguero-Gil and Comelles, 2014), the role of folk medicine had been marginalised by the end of the 1950s. The SOE played an important role in the medicalisation of the population, which increasingly migrated from the countryside to urban areas.

40The greater access to medical care was not matched by the development of public health policies. The new popular terminology which grew up around the ‘seguro’ highlighted the degree of medicalisation that had been achieved and therefore, to a certain extent, the propaganda value of the SOE for the Regime. Of the new institutions, hospitals became known as ‘residencias’ or ‘ciudades sanatorias’ and clinics or infirmaries were labelled ‘ambulatorios’.

41The SOE and later the health care provided by Social Security created demand criteria based exclusively on healing. Until the 1960s, the health system had paid little attention to the health education of the population. Only after the first democratic polls were held to elect local authorities did the town councils of big cities and some pioneer primary health centres begin to offer health care that integrated both preventive and healing activities, including those related to reproductive health (Ignaciuk and Ortiz Gómez, 2016). They were developed, above all, in the context of community nursing, and thus health education and the promotion of health came to represent an important feature of the identity of this professional sector (Pérez Mora, 2015). The ‘seguro’ scheme consolidated the status of the doctor, not only as an intellectual authority, but also as a ‘real’ authority in relation to everything connected to the health system. The doctors’ monopoly in prescribing drugs was particularly significant after the 1950s, given the crucial role of antibiotics. Nursing professionals were considered mere doctors’ assistants. Finally, doctors determined a model of the surgical and maternity hospital which led to the hegemony of hospital-centrism during the Transition (Comelles et al., 2017).

The path to a hospital-centred healthcare system

42The 1945 plan based on the study of De la Quintana and Espinosa Ferrándiz (1944) to build enough hospitals and outpatients departments to care for the members of the health insurance scheme failed to achieve its aims (Pieltáin Álvarez-Arenas, 2003; Pons Pons and Vilar Rodríguez, 2014: 137-144; Vilar Rodríguez and Pons Pons, 2016). Although the authorities published triumphalist appraisals (Instituto Nacional de Previsión, 1947; 1951; 1952), there was no real increase in the rate of construction of new healthcare premises until 1954. Twenty years after the implementation of the SOE, Spain still suffered from a lack of public hospital beds in comparison with European standards. The SOE was forced to turn to the healthcare facilities run by the official trade unions and mutual and private insurance companies (Pons Pons and Vilar Rodríguez, 2014: 236-238). Such insurance companies, which were also used as providers and managers of health care, were widespread in the most industrialised regions, especially in Catalunya. Still used by workers in the higher income brackets and therefore outside the SOE, the mutual system was less expensive and provided better services (Pons-Pons and Vilar-Rodríguez, 2017: 6-9).

43The distribution of hospitals belonging to the various systems (which also included municipal, provincial, Church and military facilities) is the subject of an ongoing project being developed by a team of economic historians (Vilar Rodríguez and Pons Pons, 2016). But it is clear that there were serious inequalities in regional distribution and the private sector retained great relevance.

44Hospitals were the first target that attracted the attention of reformists before proposals were made for the healthcare system as whole. In the 1960s, hospital planning, especially in Catalunya, was addressed by a group of doctors which formed around the paediatrician Ignasi Aragó Mitjans (1916-2012). From 1958, he was the editor of a journal (Estudios sobre Hospitales y Beneficencia, 1956-1968) that introduced international ideas and commented on hospital-related experiences (Aragó Mitjans, 1961) mainly in French-speaking countries (León and Sarrasqueta, 2017). However, the group had no practical influence in the short term.

45As hospitals received more state investment in the late 1950s and 1960s, so doctors saw jobs in these institutions as a way to improve their professional standing. Many of those that worked as consultants at public hospitals in the morning had private practices in the evening, and the reputations they gained in their public posts guaranteed them high earnings in their work with private patients. Consequently, hospitals proved tempting to young doctors with the ambition to develop a prestigious and profitable career practising high-tech medicine. This partially accounts for the central role of the hospital in the plans for reforming the Spanish healthcare system, even though the rhetoric focused on the social determinants of health, preventive medicine and health education. This was especially relevant in Catalunya, where following the tradition of the work of the Mancomunitat de Catalunya (Sabaté i Casellas, 2014; Aragó Mitjans et al., 1969) the emphasis on decentralisation with hospitals as the main reference was extremely common.

46Only with the rise in the number of hospitals in the late 1960s did people recognise their value as an essential element of care provision (Comelles et al., 2017). In such European countries as France, the central role of the hospital had become an established fact by the 1950s (Steudler, 1974; Herzlich and Pierret, 1984). A similar situation also existed in the United Kingdom following the creation of the NHS in 1948 (Helman, 1978, 2004; Gorsky, 2008).

47The process of medicalisation centred on the hospital gained in intensity in the 1970s. This occurred in a context in which, paradoxically, the institution appeared to have less to offer due to the ever-increasing demand for treatment for chronic and hereditary-degenerative conditions. There was no place for continuous care in the ‘seguro’, and therefore the growing hegemony of the hospital was based not so much on the health needs of the population as on economic priorities and corporate interests.

48Carulla’s proposal in 1939 to set up a healthcare system based on social insurance to cover the majority of the population had thus been achieved by the end of the 1960s, centred on the hegemony of the hospital and healing medicine. Rural areas, however, followed a different path, which requires a separate analysis.

Rural doctors and the Sección Femenina

  • 25 The idea was that they provided health care for the poor at their surgery (usually their own home) (...)
  • 26 Orders of 25 November 1947 and 26 January 1948.

49The municipal framework of the Antiguo Régimen, which ensured the presence of doctors in rural towns, was maintained throughout the nineteenth century and the early years of the twentieth, although it came increasingly under the control of state regulations that clearly defined the profile of doctors appointed to provide health care to the poor, and the structure of the districts in which they practised (Valenzuela Candelario, 1994; Villarino Samalea, 1997). Towns and villages were divided into various categories, depending on population, which determined the salary of the district doctor. The smallest villages were to join together to form a medical district. The doctors had not only to visit the poor in each locality but also to carry out public health activities assigned to them by the authorities. In fact, they were the medical officers of the villages where they practised. They also treated people officially above the poverty line through the above-mentioned system of ‘iguala. In the larger villages, the better-off received private treatment. In 1934, a new regulation recategorised rural doctors as civil servants, under the name Asistencia Pública Domiciliaria (public home care) doctors or APDs,25 and centralised the recruitment system, previously in the hands of the local authorities. The APDs were part of the General Health Board, as we have seen, a health organisation independent of the SOE. From 1942, only in the larger towns were APD doctors paid by the municipalities; in the case of villages with under 10,000 inhabitants, their salaries were paid from the general state budget. The APD scheme was in force when the deployment of the SOE began in urban areas. In 1948, the APD and SOE doctors were unified,26 but in practice, there were two independent healthcare networks – one urban with SOE doctors, and other rural with APDs. Rural workers had to pay for prescriptions (a percentage of the price), while SOE beneficiaries obtained their drugs free of charge. Only when in 1959 a healthcare system similar to the SOE was extended to the rural milieu (Vilar Rodríguez and Pons Pons, 2015) did APD doctors begin to have a relevant role within the insurance scheme and did rural patients receive, more or less, the same rights as urban ones.

50Working conditions were hard for rural doctors, given their isolation, scarce resources and absence of free time: they were on duty 24 hours a day every day of the year. They had to cope with serious problems, such as the infant mortality rate (higher in rural areas), endemic diseases, usually linked to poverty, and the absence of sanitation infrastructure such as sewerage or piped water. On occasions, given the lack of nearby hospitals, they were required to carry out quite complex surgical operations. The delay in the inclusion of rural workers meant that the SOE failed to provide a solution to these doctors’ unfavourable working conditions during the 1940s and 1950s.

  • 27 See, for example, an interview with a medical doctor published in Tribuna Médica, 31 December 1965, (...)
  • 28 There was a proposal to build a monument honouring rural medical doctors (Tribuna Médica, 24 Octobe (...)

51There can be no doubt that APDs, medical assistants and municipal midwives (Clos, 1976; Clos et al., 1980) played a significant and yet underrated role in the medicalisation of rural areas under Francoism. All these local health professionals, less privileged than their colleagues who practised in urban areas, undertook their work with a vocation and commitment which is explicit in the correspondence27 published in professional journals (De Lera, 1966).28 In the field of public health and health education, their role was relatively modest, in spite of some interesting proposals which failed to materialise (Espriu Castelló et al., 1979). The rhetoric on vocation did not prevent the APDs from making numerous complaints about their salaries. They believed that their social situation and economic hardships were an affront to their inherent technical and intellectual abilities as university graduates.

52The shortcomings of these doctors in the health education of the rural population, in part due to their scepticism about its value, were countered by the role of the Sección Femenina. In order to implement its plans for the political indoctrination of the population, contribute to the construction of the ideal Francoist woman as wife and mother and alleviate the conditions of rural life, the Sección Femenina carried out health education measures in the rural milieu that contributed to the medicalisation of the people. Prioritising the world of rural Spain was an ideologically based decision. The Regime considered that peasants personified the traditional Spanish values that the Movement wished to restore. Spanish fascist thought was strongly pro-agrarian and sought to combat the marginalisation and abandonment of many rural communities. We will focus briefly on two Sección Femenina programmes of specific relevance to the medicalisation process: the divulgadoras rurales (rural health popularisers) and the cátedras ambulantes (mobile training centres).

  • 29 The section devoted to rural popularisation was officially launched on 12 July 1941. In the documen (...)

53The rural health popularisers began work in villages in 1940,29 focusing their activities on reducing child mortality and teaching hygiene and correct eating habits. In preparation, they attended 45-day residential group training courses taught by Sección Femenina officers and health professionals. Between 1943 and 1950, some 1,200 rural health popularisers were trained every year, although there were never more than 3,000 active at any given time because many left the service to marry or for other personal reasons (Morales Villena and Vieitez Cerdeño, 2017: 191). They worked almost as volunteers, receiving only a small stipend for their labour. Many came from the same villages in which they worked, since it was accepted that volunteers from the city would find it difficult to carry out their assigned roles in rural areas.

54The mobile training centres were convoys of trucks and trailers that travelled from small town to small town to provide educational, health and social services, and to recover and preserve local folklore (Rebollo Mesas, 2005; Gómez Fernández, 2012). Each team included a medical doctor. They initiated their work in 1946, and between 1954 and 1956 were present in almost all provinces. Their functions included educating women in home economics and providing various forms of social support. Through the rural populariser, who was part of the team, they played a role in health education; administered basic care, vaccines and medication; and distributed kitchen and home utensils (Maceiras-Chans et al., 2018). In addition to living quarters for the teaching staff and health professionals, and mobile classrooms, some convoys included a clinical truck equipped with X-ray equipment, an autoclave, an examination table and a small laboratory.

55From an historical perspective, these activities were innovative and conceived along the same lines as the ‘barefoot doctors’ working in the Third World. They probably played a significant (although difficult to evaluate) role in the improvement of hygiene and the reduction of child mortality and brought medical services to rural areas. Nevertheless, their activity was tarnished by the inquisitorial and propagandistic character of the Sección Femenina during the Franco regime. The health popularisers wore white aprons with the Falangist coat of arms and other Falangist symbols. This profile generated resistance because of the hostility of part of their intended beneficiaries towards anything connected with the Falange Española Tradicionalista y de las JONS. The rural popularisers gathered data on all aspects of the social life of the villages in which they worked. Furthermore, they embraced the task of encouraging the population to respect the Catholic sacraments: baptisms, communions, weddings and so on. Such efforts were not welcomed by many sectors of the population.

56The reduced importance of health education in the work of the Sección Femenina after the 1950s can be traced to demographic shifts and changes in the healthcare needs of the population. By the late 1950s child mortality was no longer a serious health problem in Spain. A contributing factor to this in urban areas was the extension of maternal SOE and childcare at a time when there was massive rural-to-urban migration. From 1961 onwards the most influential health education activities addressed nutritional education through the EDALNU programme, set up after agreements with Unicef and FAO. Thousands of nutritional popularisers were trained within this framework (Tormo Santamaría et al., 2017).

  • 30 See, for example, the articles on popular medicine published in the journal Tribuna Médica, 1971, V (...)

57The inclusion of the peasant class in the SOE, within the context of the migration to the towns between 1950 and 1970, improved access to resources considerably. The role of the popular care providers diminished. Although in the 1960s and 1970s anthropologists still described the activities of popular healers (Kenny and De Miguel, 1980; Primeres Jornades [...], 1982), there is no doubt that their role was in decline. Nonetheless, professional journals did continue to report on popular medicine in country areas.30

Towards a new health system31

  • 31 For a detailed study of this stage, see Perdiguero-Gil and Comelles (2019).
  • 32 On the health aspects of the II Social Development Plan, see Yuste and Zapatero (1969).

58In 1975, on the death of Francisco Franco, 80.86 % of the population enjoyed healthcare protection under the Seguridad Social (Fundación FOESSA, 1983: Vol. 2, 809). However, from various perspectives, the health system was judged to be unsustainable. The organisation responsible for health care, the National Welfare Institute, had proved unable to overcome the many problems it faced: an economic deficit, failings in cover and management, low-quality primary health care, an inadequate hospital network and dissatisfied health workers and users. The Economic and Social Development Plans (1964-1967, 1968-1971 and 1972-1975)32 had scant influence in the health sector (De Miguel, 1979: 55-73). Several initiatives, such as the Plan Sanitario Nacional (National Health Plan) designed to coordinate the health activities of the General Health Board did not have a real impact (Rodríguez-Ocaña, 2018).

59The Regime was not interested in developing a modern healthcare system comparable to those of the more developed European countries. After the introduction of the SOE as a propaganda weapon exalting the peace and social justice established by the dictatorship, the state did not make an economic commitment to health insurance, but rather over the years maintained a merely nominal contribution to the plan. The issue of universal health care did not arise; given that the system was linked to the insurance of workers, it was economically inviable. Franco’s tax laws were designed to favour those factions that supported the Regime and were based on the premise of low state expenditure, which made it impossible to fund social welfare. The SOE developed without technical criteria, coherence or coordination. As a result, the hospital network did not respond to the needs of the population but rather to the interests of professional groups and the construction companies that built it.

60Within ten years of its implementation, the system was operating at a deficit and the situation deteriorated over time (Pons Pons and Vilar Rodríguez, 2014: 142-143). When Social Security began to enjoy a surplus in the 1960s, the Regime failed to reinvest in the system (Vergés, 1976: 170-172), but instead used the surplus to fund other economic activities and to benefit certain pressure groups (Pons Pons and Vilar Rodríguez, 2014: 231-232).

  • 33 Order of 26 December 1974.
  • 34 Comisión Interministerial para la Reforma Sanitaria. Informe al Gobierno (June 1975).
  • 35 See preliminary analysis on these ‘manifestos’ in Pérez Iglesias (1992) and Maestro (1992).
  • 36 Leaving aside the articles published in professional journals and others that appeared in general m (...)

61The Francoist healthcare system was therefore in a severe crisis by the beginning of the 1970s and was criticised from various sides, even by reformists inside the Regime. The government was slow to react and not until the end of 197433 did it set up a committee to study health reform, which produced its report at the end of June 1975.34 The proposals it made had no practical repercussion (De Miguel, 1979: 70-72). By then, doctors belonging to the forbidden left-wing parties (prior to their legalisation in 1977) and trade unions35 had published plans for replacing or reforming (this term was less common) the Francoist Social Insurance scheme.36 Most proposals were written by communist and socialist doctors though some economists and journalists also contributed. There was a clear preponderance of plans written from Catalunya for Catalunya, although some came from Madrid and Valencia.

62All the alternatives put forward a National Health Service with universal coverage for the Spanish population, focusing on health rather than disease, and financed by the State budget. The aim was to identify the biological, environmental and social causes of diseases in order to preserve people’s health through preventive and public health activities, including health education. The fight to preserve health, and the special focus on environmental and social factors, was considered a powerful tool in establishing democracy and the first step towards a socialist society. There was no way to improve social conditions without a new political system. Health had a revolutionary role and, at the same time, was only possible with political change.

63In this context, the participation of the population in the planning, management and assessment of the health service was considered essential. Health boards organised at different levels (national, regional and local), with the involvement of health authorities, health professionals and the general public, were thus proposed as popular control mechanisms.

64In order to overcome the dissociation between healing and preventive activities, the health service needed to offer comprehensive services: health education, public health and preventive medicine, health care, rehabilitation and social reintegration. Importantly, the plans gave a pivotal role to health education, on a par with health care, and highlighted the absence of these activities during Francoism.

65A key issue in all the proposals was the need to avoid inequalities of access by regionalising the health services. This meant different levels of health care were established in particular zones or regions. It also included devolving the management of health care and public health activities to the autonomous regions approved by the 1978 Constitution.

  • 37 This extreme right-wing party was set up in 1976 as the self-proclaimed true heir of the historical (...)

66Despite the absolute irrelevance of the Falange on the political landscape after the death of Franco, it is worth noting that the proposals made by the Falange Española de las JONS37 in 1977 for reforming the social security and health system (Falange Española de las JONS (auténtica), 1977) were the same as those proposed by left-wing doctors.

  • 38 This was the title of the Interior Ministry, with its strong emphasis on public order and police co (...)
  • 39 Federico Mayor Domingo (died 1997) was an important figure in the pharmaceutical industry. He found (...)

67From the government side, there were no initiatives until the first democratic elections in Spain since 1936 were held in 1977. A Ministry of Health and Social Security was set up in June 1977 bringing together the General Health Board (until then, part of the Ministerio de Gobernación38), the healthcare offices of the Ministry of Labour and the varied health-oriented bodies of other government departments. In 1977, the Ministry of Labour also published one report on the Social Security system, ten years after its implementation, with ‘an analysis of its real and urgent problems’ (Ministerio de Trabajo, 1977: 7), and another on pharmaceutical care (Mayor Domingo, 1977). The same year, a first draft of a health law was produced by the new department of Health and Social Security. Two further reports, also coordinated by Mayor Domingo39 (1979a, 1979b), were published on the health needs, healthcare resources and health in the rural milieu. In the following years, there was a number of regulations, drafts, publications and public debates, including those on the transfer of health competencies to the autonomous regions, which began in 1981.

  • 40 Pons Pons and Vilar Rodríguez (2014: 296-312) and Vilar-Rodríguez and Pons-Pons (2018) have researc (...)

68In-depth analysis of this period until the LGS (1986), under the government of the Partido Socialista Obrero Español,40 with special attention to changes in the population’s health culture, is part of our ongoing research project, based on the study of a huge number of documents, which will be the subject of future publications.


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1 The 1978 Constitution recognises the right of citizens to health protection and grants the public authorities powers to organise public healthcare services and preventive activities.

2 To date, there has been little research on the history of health system reform (Navarro and Elola, 1995; Ortega and Lamata, 1998; Guillén Rodríguez, 2000; Pons Pons and Vilar Rodríguez, 2014: 201-340). Some work has highlighted the concessions and contradictions of the process, especially in relation to the ‘psychiatric reform’ and some authors have provided more or less critical assessments of the reform as a whole (Lamata Cotanda, 2003; Sánchez Bayle, 2006; Lamata Cotanda, 2011).

3 Within Francoism there were, of course, ‘reformers’ who sought to change some areas of government action. They usually failed in their attempts, but analysis of their proposals can reveal certain trends. We have shown this in the case of health education in schools (Terrón Bañuelos et al., 2017).

4 To avoid the inclusion of a very large bibliography in the article, we elude bibliographical references on the topics of this section, which we consider well known.

5 Poor Law Amendment Act, known as the New Poor Law.

6 The regulation for its implementation was published 14 March 1852.

7 The first phase of the medicalisation process can be considered a Late Medieval phenomenon, at least in Mediterranean countries, where the first universities were established and there were university-trained doctors appointed by towns.

8 The Mancomunitat de Catalunya was an institution that provided a certain degree of autonomy for Catalunya. It carried out pioneering programmes in health, education and social services. For health policies see Sabaté i Casellas (2014).

9 The data used by Carulla came from de la Quintana and Aznar, although he did not cite specific works by these authors. Primitivo de la Quintana López (1907-1996) was trained as a medical officer and after the Spanish Civil War held the post of Chief Medical Officer of Madrid (Perdiguero-Gil et al., 2017). Severino Aznar Embid (1870-1959) was a pioneer of sociological studies in Spain, was involved in the development of social welfare policies from the beginning of the twentieth century and served as Head of the Social Welfare Services from March 1938 to December 1938. Both figures played a significant role in the setting-up of the SOE.

10 Under Franco’s dictatorship, the term ‘Victory’ acquired an ideological, symbolic and practical meaning as it divided the country between winners and losers.

11 In 1934 the Falange and the Juntas de Ofensiva Nacional Sindicalista merged. In 1937, at the height of the Civil War, Franco unified all the political organisations that had supported him in a single party, the Falange Española Tradicionalista y de las Juntas de Ofensiva Nacional Sindicalista, later rebranded as the Movimiento Nacional. For the Regime’s social welfare policies, especially those developed by Auxilio Social and the Sección Femenina, see Richmond (2003) and Cenarro Lagunas (2006, 2009). It is not possible here to give an extensive list of works on Francoism. The titles quoted are simply examples of the most relevant works.

12 This system was known as iguala.

13 ABC, 26 June 1949, 16.

14 See the discourse of the Ministry of Labour: La Vanguardia Española, 13 July 1950, 5.

15 See also the article Encuesta sobre la seguridad social. Contesta el Doctor Don José Espriu Castelló. La Vanguardia Española, 17 December 1966, 27.

16 We can see this kind of criticism in the article Sobre el personal sanitario y sus problemas y necesidades. Horizonte, 3(18-19) (1951), 12-14. Similar criticism was also voiced in other provinces, for example, in the Hoja informativa del Colegio Oficial de médicos de Teruel, July 1954, 24, 1-2.

17 These cooperatives, known as igualatorios colegiales, developed out of similar ones which had been in operation before the insurance law of 1954.

18 On his role as a medical populariser, see Comelles (2015).

19 The model spread throughout Spain and gave rise to ASISA (Asistencia Sanitaria Interprovincial de Seguros, S.A.), today one of the most important health insurance enterprises in Spain.

20 The non-scientific journals for medical doctors frequently published complaints about the organisation of the SOE. The most relevant are Profesión Médica (1944-1968), when it was a supplement of the scientific journal Gaceta Médica Española (1926-1978); Horizonte (1949-1954); and Tribuna médica (1964-1996), published by a pharmaceutical company (Antibióticos, S.A.). Less relevant are Noticias Médicas (1967-2016) and Profesión Médica (since 1969). See also the article Después de más de veinte años de implantación del SOE el médico está insatisfecho. La Vanguardia Española, 29 December 1966, 7.

21 Seguro de enfermedad. Las prestaciones graciables, ABC, 11 January 1956, 29. Seguridad obligatorio de enfermedad. Prestaciones económicas, ABC, 15 January 1956, 52. Sobre el seguro de enfermedad. Afiliación y localización de asegurados, ABC, 19 January 1956, 24. Seguro de enfermedad. El médico de familia, ABC, 26 January 1956, 37. Sobre el seguro de enfermedad. Actuación médica en equipo, ABC, 5 February 1956, 63. Seguro obligatorio de enfermedad. Médicos especialistas, ABC, 8 February 1956, 30. Seguro Obligatorio de Enfermedad. El reintegro, ABC, 15 February 1956, 38. Seguro obligatorio de enfermedad. El orden de visitas en las residencias, ABC, 16 February 1956, 35. Seguro obligatorio de enfermedad. Los servicios de urgencia, ABC, 18 February 1956, 24. Seguro obligatorio de enfermedad. Lo subalternos y ‘su público’, ABC, 23 February 1956, 34. Seguro obligatorio de enfermedad. La colaboración del empresario, ABC, 29 February 1956, 31. Seguro obligatorio de enfermedad. Misión de las visitadoras, ABC, 2 March 1956, 29. Seguro obligatorio de enfermedad. El espíritu de ahorro en la asistencia, ABC, 20 May 1956, 68. Seguro obligatorio de enfermedad. Las prórrogas, ABC, 4 July 1956, 26. Seguro obligatorio de enfermedad. Los asesores médicos, ABC, 5 July 1956, 25.

22 Egea, L. (1964). El teléfono inútil, La Vanguardia Española, 5 April, 31. Querol, J. (1965). Problemas en el S.O.E., La Vanguardia Española, 16 January, 22. Hospital Rodes, J. (1965). Las bromas que son de veras. La Vanguardia Española, 30 May, 62. Latrilla, F. (1965). Problemas en el S.O.E., La Vanguardia Española, 16 January.

23 See, for example: Los ‘seguros sociales’ del franquismo: un latrocinio a cara descubierta, Mundo Obrero, 30 July 1954, 4. En torno a la Ley de Seguridad Social, Mundo Obrero, 16 February 1964, 5. El descontento de los médicos, Mundo Obrero, 1 July 1966.

24 It was eventually published without censorship in 1976 (Candel, 1976).

25 The idea was that they provided health care for the poor at their surgery (usually their own home) and at the patient’s home when the illness was more serious. The Decree of 29 September 1934 clearly set out the duties of the APDs. Beyond health care they had to deal with miscarriages and dystocic deliveries as well as carry out public health activities and other tasks associated with different government departments. The same year decrees were published regulating the activities of other health professionals working in rural districts: dentists, chemists, midwives, veterinary surgeons and medical assistants.

26 Orders of 25 November 1947 and 26 January 1948.

27 See, for example, an interview with a medical doctor published in Tribuna Médica, 31 December 1965, 85, 7.

28 There was a proposal to build a monument honouring rural medical doctors (Tribuna Médica, 24 October 1964, 23, 4-5). The initiative obtained considerable support. See, for example, Tribuna Médica, 1964, year 1, number 24, 31 October 1964, 24, 7; Tribuna Médica, 7 November 1964, 25, 11; Tribuna Médica, 19 December 1964, 31, p. 6.

29 The section devoted to rural popularisation was officially launched on 12 July 1941. In the documents they are variously described as divulgadoras rurales (rural popularisers), divulgadoras sanitarias rurales (rural health popularisers), and divulgadoras socio-sanitarias (social and health popularisers). In any case, their activities were always health-related.

30 See, for example, the articles on popular medicine published in the journal Tribuna Médica, 1971, VIII(370), 20-21: Cataluña (1); 1971, VIII(371), 16-17: Cataluña (2); 1971, VIII(372), 14-15: Madrid (1); 1971, VIII(373), 18-19: Madrid (2); 1971, VIII(379): Canarias (1); 1971, VIII(380): Canarias (2); 1971, VIII(381): Canarias (3); 1971,VIII(382): Vieja Castilla.

31 For a detailed study of this stage, see Perdiguero-Gil and Comelles (2019).

32 On the health aspects of the II Social Development Plan, see Yuste and Zapatero (1969).

33 Order of 26 December 1974.

34 Comisión Interministerial para la Reforma Sanitaria. Informe al Gobierno (June 1975).

35 See preliminary analysis on these ‘manifestos’ in Pérez Iglesias (1992) and Maestro (1992).

36 Leaving aside the articles published in professional journals and others that appeared in general magazines such as Cuadernos para el Diálogo and Triunfo, the above-mentioned comments by Solé Sabarís (1965: 9-12; 99-108; 125-135; 197-221; 256-264; 277-305) on the Spanish translation of Hatzfeld on liberal medicine may be seen as one of the first articulated criticisms of the Francoist healthcare system. Subsequently, dozens of books were published in the 1970s on health reform, too numerous to be referenced here. The books and articles on the topic published by the medical sociologist Jesús M. de Miguel (for example, De Miguel, 1979) are also significant. Both the proposals put forward by the left-wing parties and trade unions and the studies of De Miguel deserve a detailed analysis beyond the scope of this article.

37 This extreme right-wing party was set up in 1976 as the self-proclaimed true heir of the historical Falange Española, founded in 1934 and merged with the Juntas de Ofensiva Nacional Sindicalista (JONS). It played a destabilising role during the early years of the transition to democracy. In the 1977 polls they obtained only a 0.21% share of the vote.

38 This was the title of the Interior Ministry, with its strong emphasis on public order and police control during Francoism.

39 Federico Mayor Domingo (died 1997) was an important figure in the pharmaceutical industry. He founded the above-mentioned journal Tribuna Médica. The fact that he acted as the general coordinator of the studies published in 1977 and 1979 was due to the patronage of the joint committee of the pharmaceutical industry and Social Security. The technical work was coordinated by Victorino Jimeno Martínez, a sociologist who years later published a book on the rational use of drugs (Jimeno Martínez, 1991).

40 Pons Pons and Vilar Rodríguez (2014: 296-312) and Vilar-Rodríguez and Pons-Pons (2018) have researched the general press to describe these debates, showing the deep disagreements among the main political parties.


Instituto Internuniversitario López Piñero. Universidad Miguel Hernández of Elche, Alicante, Spain

Medical Anthropology Research Centre, Universitat Rovira i Virgili, Tarragona, Spain

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