By 1975, 80 per cent of the Spanish population had health coverage through social security either as workers or dependents, but the system remained fragmented at the administrative and organizational level (FOESSA 1983: 805). The starting point for democratic Spain is noteworthy: coverage rates were high under the military regime and most workers were in the formal sector.
Despite having sworn to uphold the ideals of the Franco’s Movimiento Nacional, when Juan Carlos I was named King in 1975, he moved forward with a political reform law that was passed by the legislature and then put to referendum in 1976. This reform legalized political parties and paved the way for the writing of the new constitution. In 1977 the Pactos de la Moncloa (Moncloa Pacts) were signed by the parties with representation in congress, as well as business and unions, with the goal of pacting and smoothing the transition process. The pacts were also aimed at developing a quick plan of action regarding the economy, which was in inflationary free-fall. Though not what they are best known for, the pacts began the process of pulling social security policy making out of the hands of the small cadre of physicians and politicians who had controlled it under Franco (Guill´en and Cabiedes 1997: 323). Because the old guard was never ousted, the conservative parties that formed when the party system was legalized were the direct heirs of the ruling elite under Franco. Many of Franco’s ministers and legislators continued in politics at the center or in the ACs. This was the case for Adolfo Su´arez, who created theUni´on del Centro Democr´atico (UCD, Central Democratic Union) to run as a center right, democratic and reformist coalition in the first elections. The UCD won in 1977 with 34.4 per cent and governed Spain from 1977 to 1982, after also winning the first elections in 1979 under the democratic constitution. In 1979 the UCD government was formed with the support of Alianza Popular (AP, Popular Alliance), a coalition of harder core right wing parties that included many unreformed members of the regime. Internal conflicts within the UCD caused Su´arez to resign and with the economic crisis of 1981 and increasing unemployment and hardship, the coalition crumbled and disappeared. The modern right of center party, the PP was born from reform of the AP in 1989.
Spain uses a closed list proportional representation system for elected offices, ex- cept the Senate, which is elected partly in a plurality system from the provinces and
partly by AC legislatures. The Spanish President is chosen by the lower house of Parliament, the Congreso de Diputados, and formally named by the King10. The Cabinet is chosen and organized by the President and if the President falls, so do the Ministers. Unlike Brazil where ministerial portfolios are often distributed to powerful politicians and run with great autonomy, Spanish Ministers are more tightly tied to the ruling party and the President. One would not generally expect to see Spanish ministers acting with significant ideological autonomy or against the platform of the President, though cabinets still contain significant levels of ideological variation and conflict over policies, as we shall see.
The first Ministerio de Sanidad (Ministry of Health) was created in 1977 by the constituent legislature after Franco’s death (Real Decreto 1558/1977), though was combined with the Social Security Administration at this time. Under the national leadership of the UCD, there were six health ministers in five years. During the demo- cratic transition a temporary health financing formula was developed, which lasted only until the creation of a permanent system and did not address the entrenched in- equalities between the ACs. At the outset, health care was financed slightly above 75 per cent from Social Security and 20 per cent from general taxation (L´opez-Casasnovas 1998). In 1978, as a cost containment measure, a 40 per cent copay on pharmaceuti- cals was introduced, except for retirees, and has remained in place, since.
A number of major reforms took place during the UCD period that began the process of addressing the issues that were holding back the development of an equity- enhancing health system. One was the reform of the tax system in 1977-1978, which introduced direct taxation of personal income for the first time with the Impuesto sobre la Renta de las Personas F´ısicas (IRPF, Ley 44/1978). Spain was in dire need of increased revenue and in the process of negotiating entrance into the EU, which was
pushing for the implementation of a progressive income tax. This reform was pacted with the PSOE and the UCD received harsh criticism internally for not supporting conservative positions, taking on “progressive” legislation that was considered the terrain of the socialists11.
In 1978 the World Health Organization and UNICEF had called a conference on primary care, which was sponsored by the USSR and held in Alma-Ata, Kazakhstan. The The Declaration of Alma-Ata was significant in the international health com- munity and influenced thinking about the organization of care in both Spain and Brazil, pushing policy makers toward integrated public health systems founded on primary care. The UCD, with the cooperation of all the ACs and broad consensus among health professionals about the need for investments in primary care, passed Real Decreto 2221 of 1978 to begin the process of creating mapas sanitarios (health maps) so that policy makers could understand the actual state of health services in the country and organize the territory for the public provision of care.
Until 1979, the highest intermediate territorial level was the province. The ACs, which took on primary responsibilities in health provision, regulation, and financing, were created after democratization and after the 1978 Constitution. While historical territorial affinities existed across provinces, with varying levels of legality at different moments, these regions had never been simultaneously recognized and institutional- ized in a centralized framework. As we shall see, in some of the ACs that eventually formed, the provincial composition of the territory was quite different from what had been expected by political elites at the central level.
The 1978 constitution paved the way for the creation of the ACs (Art. 147), which took place between 1979 and 1983 through bilateral negotiations and passage of Estatutos de Autonom´ıa (Autonomy Statutes) that were unique for each newly
created AC. The three “historic nationalities” that had acquired special statutes under the Second Republic—the Basque Country, Catalonia, and Galicia—were guaranteed a fast track to autonomy called the v´ıa r´apida (Art. 151). For these communities, the Statute was developed by gathering the central government deputies and senators elected from the provinces of those areas to write a proposed Statute, which then had to be passed by an absolute majority of that group, then passed by the Constitutional Commission of the lower house and within two months put to a referendum in the affected provinces (Art. 151.2).
While this avenue was designed for these three communities and was meant to be a more difficult but faster way to gain the maximum competences permitted (Art. 149), the provinces of Andalusia opted for this avenue as well. In fact, the UCD preferred only limited decentralization and had not planned for any other ACs to acquire autonomous political institutions. But when Andalusia pressed forward it forced the major political forces to regroup and negotiate a special exception, while trying to avoid having other ACs go down the same path. Thev´ıa lenta was to be the process of limited autonomy for the rest of the country and the process was initiated by provincial and local governments and then submitted to the full lower house for passage as organic law (Art. 143). This avenue was designed to yield lower levels of policy devolution, more slowly and in general has had this effect.
The different paths to autonomy were not predetermined. These were critical junctures in a highly volatile transition process. Once a path to was chosen, it defined the next few decades and ensured that an AC would either have a high level of policy autonomy in a wide variety of areas, quickly, or that the process would be slower and more limited. For the UCD, it was a story about attempting to contain regionalization as much as possible by forcing all but the most strident onto a slow path with Statutes that could only be renegotiated every five years. But because of this vision, the v´ıa
lenta was immediately stigmatized as being for less capable, less “special” ACs. The UCD originally planned for only these three special ACs to have directly elected institutions of self-government, which deepened the perception that democracy was tied to decentralization.
The UCD’s reluctance to extend democratic institutions to all the new ACs so- lidified support for the v´ıa r´apida on the left in most provinces, which would have been the only way to guarantee elected autonomous institutions. This attempt to limit democratic political decentralization created high levels of partisan conflict and caused the provincial left to push much harder for substantive devolution than it might have if democracy and decentralization had not been so tightly intertwined. Herein lies one key to the association between democracy and decentralization in Spain. Because of the legacy of the dictatorship, the assumption that a strong Spain meant weak regions existed on both the left and right and propelled these forces to- ward often dogmatic stances in favor of particular territorial arrangements that have muddied their ideological policy preferences over time. At this defining moment in the democratic transition, the attempt of the UCD to limit democratic decentralization helped solidify support for broad devolution—beyond just the creation of democratic institutions—for actors on the left.
The government of Adolfo Su´arez had created a commission in 1979 to advise on “rationalizing” the process of autonomy. The central PSOE supported the idea of a unified strategy because it wanted to expand legislative institutions to all the ACs. It was also concerned about what would happen if ACs without a history of self-government opted for the v´ıa r´apida but could not meet the high thresholds of absolute majorities for the provincial referenda12. This was a reasonable concern, given that it was precisely what ended up happening in Andalusia, which opted for
12El Pa´ıs 12/2/1979 “UCD y PSOE estudian una f´ormula para ‘racionalizar’ reivindicaciones
the v´ıa r´apida even though the provinces of Ja´en and Almer´ıa did not reach the minimum threshold. But the PSOE’s commitment to democratic decentralization extended into its own internal structure and its regional affiliates expressed territorial independence. Almost all demanded higher levels of autonomy, more quickly, than the central party supported. An unintended consequence of slowing the process and keeping non-nationalist ACs out of the v´ıa r´apida was that a larger number of ACs fell into the newly created centralized health service, INSALUD.
The 1978 Constitution for the first time guaranteed health protection (Art. 43 and 49) and foresaw that it would be developed from the outset as a responsibility of the ACs (Title XIII), even without knowing how many there would be. It took five years for all 17 ACs to be created. The constitution grants the center exclusive responsibilities in establishing the minimum services to be covered under the SNS, coordinating the systems of the ACs, and legislating pharmaceutical coverage and health policy that crosses regional borders (Art. 149.16). The document considers health care separately from social security, suggesting that the framers intended to put Spain on the path toward the creation of an NHS (Alonso Olea 1994; Guill´en and Cabiedes 1996), which was also consistent with the impulses of Alma-Atal.
AC health secretariats are not hierarchically accountable to the central Ministry of Health, as they are (partially) in Brazil, but only to their AC parliament. Neither the Constitution nor later enabling legislation gave the central state authority to hold ACs accountable or for mandatory data collection that would permit independent monitoring. The courts have become the only source of arbitration over competences and are kept exceptionally busy with parties, ACs, and central actors suing each other over issues of the territorial distribution of authority. It is quite likely that the pacted transition to democracy would not have been successful if the constitution had been more explicit—its vagueness was quite intentional—yet the problems for the practice
of government later have been significant.
Social protection was reorganized into thematic institutions in 1978, with the cre- ation of INSALUD for health assistance and a stronger social security administration for financing social expenditure. Social provision was to be handled by four new agencies that took the place of the old INP. Between 1979 and 1981 all communities gained authority over public health and health care planning. While Health Minis- ter S´anchez de Le´on began the process of modernizing the newly created INSALUD, health policy and the development of the welfare state remained low on the list of political priorities, far below the broader political reform project.
Despite the lack of focus on health policy at this time, state reform continued. It had been hard enough for the UCD to force the Basques and Catalans to wait for their Statutes until after the passage of the Constitution—not a minor point of contention, but rather a fundamental question of the source of sovereignty and the definition of the future limits to autonomy that would be defined for the historic ACs. These communities had their Statutes drawn up and approved, waiting for the constitutional process to be completed. The central government passed the Basque and Catalan Statutes in 1979. The pressure of demand from these two ACs had forced a fast pace and a higher level of devolution than the UCD had wanted. For much of the rest of Spain, awareness of conflict over the territorial distribution of authority had been relatively low (Linz 1981: 21). Blow by blow coverage of the tense negotiations for Basque and Catalan autonomy in the newly-freed press captivated the country and brought these questions to the fore in other ACs, as well. The pressure for a legal, judicial, and administrative framework for the autonomy process became intense.
In 1979 theLey Org´anica del Tribunal Constitucional (LOTC, Organic Law of the Constitutional Tribunal LO 2/1979) became the supreme judicial law for the country, governing the ACs and their Statutes (Revorio 2009: 92). TheLey Org´anica Sobre las
Distintas Modalidades de Refer´endum (Organic Law Regarding the Different Forms of Referenda 2/1980) enabled the popular consultations required for beginning the au- tonomy process through the v´ıa r’apida and for ratifying the Statutes in those cases. The Ley Org´anica de la Financiaci´on de las Comunidades Aut´onomas (LOFCA, Or- ganic Law for AC Finance 8/1980) set out the framework for regional finance. This included the Fondo de Compesaci´on Interrteritorial (FCI, Inter-territorial Compen- sation Fund, Art. 16) with the express purpose of ameliorating inequalities in level of economic development between the ACs through public investments. Also created by the LOFCA was the Consejo de Pol´ıtica Fiscal y Financiera (CPFF, Council on Fiscal and Finance Policy), which coordinated fiscal policy between the ACs and the center and has become the dominant organ for intergovernmental bargaining in this arena. Table A.6 places the creation of some of these institutions in the broader timeline of fiscal changes in health policy.
An attempted coup took place on February 23rd, 1981 in which the Guardia Civil took possession of the Congress, believing the monarchy to be on its side. While there is still great speculation about the event because the King waited many hours to appear publicly and renounce the events, the coup eventually failed. Democracy in Spain is therefore not seen as fully consolidated until 1981. The negotiations and policy-making that took place during these years were constrained by high levels of uncertainty, as well as political and physical risk for reformers.
The Health Ministry was separated from the Social Security Administration in 1991. This paved the way for political decisions to be made autonomously regarding the organization of an independent health service. Health maps were drawn up during this period that allowed for assessment of where coverage was weak, while access and coverage continued to expand. In 1982 theLey de Integraci´on Social del Menusv´alido
of the disabled in the work place and granted access to health care—the first extension of health services not based on attachment to the labor market.
These pieces of legislation were primarily negotiated between the major politi- cal parties, which became the norm for major policies during the 1980s and 1990s (Encarnaci´on 2008: 9). Under UCD leadership, the Health Ministry tried to tighten the relationship between the government and the private medical establishment13.
In 1981 health competences were devolved to Catalonia (Real Decreto 1517/1981)— though because the state model was still in flux and the SNS was still five years out, its level of authority in health material was contested politically and in the courts.
Because decentralization was a priority for all the political forces that had been banned under Franco and substantive social policy decentralization was written into the Constitution, the devolution process was part of political reform and not treated as a secondary priority, as social policy reform generally was during this time. Therefore, while health reform did not take place countrywide, devolution of health responsibil- ities continued.
After the attempted coup, pressure within the PSOE for support of harmonization in the autonomy process was strengthened. The UCD feared centrifugal decentral- ization pressures that might create chaos and total asymmetry, or even independence for some ACs. The PSOE feared centrifugal decentralization both from a distribu- tional perspective, with an intellectual base in the centrism of socialist doctrine, but also from a pragmatic concern about the level of autonomy the anti-democratic right in Spain would tolerate before attempting to retake the state. After the 1981 coup attempt, with the constitution still young, this was not a paranoid concern.
In 1982 theLey Org´anica de Armonizaci´on del Proceso Auton´omico (LOAPA, Or- ganic Law to Harmonize the Autonomy Process) was passed with these ends in mind,
13El Pa´ıs2/14/1982 “La idea de estrechar relaciones etnre el Estado y la medicina privada presidi´o