THE SPANISH

HEALTH PLANNING 1964-1975*

JESUS M. DE MIGUEL Yale University. U.S.A. and Universidad Aut6noma de Barcelona,

EXPERIENCE:

Spain

Abstract-This is a study of health planning processes in an authoritarian system, analyzing the three first Spanish Health Plans (1964-67, 1968-71 and 1972-75), as published by the Comisaria del Plan de Desarrollo Econdmico y Sociul de la Presidencia drl Gohierno and officially approved by Las Cortex We examine the balance between economic and social development in such plans; the objectives and peculiarities of each of these three governmental “white papers”; the relationships between yearly projections and results; and the ideologies (or mentality: Linz 1964) implicit in the Health Plans.

The concept of socio-economic planning in Spain is relatively new. starting in 1964 as a result of the Stabilization Plan of 1959, the World Bank Report published in 1963 [l], and the desires of integration into the European economic community. Originally, these plans were inspired by the French Plans, especially the Fourth Plan. From the beginning. the Spanish plans were successful and the real GNP was growing at a rate higher than 6”/, per year. Nevertheless, periods of strong economic development (such as 1966 and 1969) were followed by periods of pronounced deceleration or recession (1968, 1971 and 1974 75) [2]. Some economic commentators suggest that Spain developed irl spite of the socio-economic plans [3]. The Spanish plans are politically dictated and the members of their commissions are not elected democratically. The model of an authoritarian regime is implicit in the organization of the Plans [4]. Democratic features were absent from the very beginning in this kind of planning: Of course. it was neither a representative nor a democratic process. The membership of the participatory instruments was not elected but appointed. The committees had no authority: they were advisory institutions. The members of these organs were not representative either in the sense of being selected by or recreating the composition of their constituencies. They were selected on the basis of their collaborative and coordinative capacities. as critical figures in effectively meshing public and private sector performances. not because of any confidence reposed in them

b! any specified group. (Anderson 1970 p. 178). The period of this planning mentality coincides with the beginning of a period of rapid industrialization of the country (196% 1973). the existence of an author* This research was partially supported by grants from the Social Science Research Council and Juan March Foundanon. The opinions expressed here are those of the author and are not Intended to reflect neither the views of those institutions nor the Spanish government. The author wishes to express his appreciation to Susan Shapiro for her critical reading of the manuscript. to August B. Hollingshead. Juan J. Linz. Jerome K. Myers and Benjamin J. Oltra for their comments and suggestions and to Joan P. Cianciolo for her technical assistance.

itarian regime with technocratic features under the leading role of the Opus Dri (1961-1971), and the ideology of drsurrollismo which tends to value economic growth over other types of development. As Murillo states : “In the ideology of development there is a touch of paternalism, of enlightened despotism, because the problem of the authentic participation of all in political-and especially economicdecisions is relegated, at least, to a secondary level. The weapon of development is often utilized (and in this point we do not refer only to Spain) to contain the possible advance of economic democracy”[5]. These plans are “indicative” [6] and not compulsory, with the exception of their application to the public sector. In being indicative, the goals and projections of the Plan do not constitute obligations for the private sector. However, the plans tend to offer benefits or incentives to the private sector when it follows their instructions [7]. The World Health Organization would term these plans “idealistic”, in which “action is encouraged by exhortation, but precise objectives or methods of achieving them are not specified” (1971:9). Socio-economic plans in Spain are divided into specific sectors, and each one includes a four-year program. The majority of these sectors (comisiones and ponencias) stress economic rather than social concerns, and particularly those of the industrial development sector. The concern for health planning is used to justify the “social” content of socio-economic plans. Actually there is no planning machinery for the health sector [S]. It has been stated that “national health planning is an integral part of general socio-economic planning”. (Hilleboe, Barkhuus and Thomas, (1972: 9). The First Health Plan states that the problems of health and social assistance are not marginal to economic development (Comisaria de1 Plan 1964:47). As both the Second and Third Health Plans mention in their introductions, the planning of sectors such as social security. health and welfare are: “The effective fulfillment of the ‘promotion of a just social order’, a fundamental goal of the State proclaimed in Article 3 of the Organic Law of January 10. 1967”. They further state that this goal was “most strictly faithful to the Principles of the National Movement, which

451

JESUSM. DE MIGUEL

452

recognize the right of all Spaniards to the benefits of social security and assistance (IX) and which stress the attempt to perfect the moral and physical health of Spaniards by all its means at hand as one of the goals of the State”. In spite of this ideological support, the Health Plans are considered the Cinderella of the socio-economic plans. The Second Health Plan noted that the commission did not have the goal of formulating theoretical or doctrinal definitions (Comisaria de1 Plan 1967: 11). In addition. the self criticism of the Health Plans is fairly limited. This contradicts the general idea that planning “presupposes some degree of dissatisfaction with the present state of affairs on the part of the planners” (Mott 1974:271). The socio-economic plans in Spain were created to coordinate the public and the private sector. In the case of the Health Plans, this objective is absent. and they tend gradually to deteriorate both in quality and quantity.

THREE

WHITE

PAPERS

The Spanish Health Plans are presented in three white papers covering the last decade: the First Plan (19641967), the Second Plan (196&1971) and the Third Plan (1972-1975) [9]. Each one of the three white papers was written by a different commission; for example the Third Plan committee was composed of 189 persons (of which only 15 were women [lo]. The Health Plans do not follow any pattern; each of the four-year plans is independent of the others and no plan considers the results of the previous ones. The Spanish Health Plans and especially the First, present a non-coordinated system of grants and/or loans for private institutions (such as the private sector. the Church, etc.). These “incentives” allow many of private health establishments to survive with a minimum control from public sources. The Second and Third Health Plans are more centralized and have a special emphasis on the rural population, two aspects that were not taken into account by the First Plan. The Second Health Plan suggests three objectives: (a) the construction of 283 houses for rural doctors; (b) the acquisition of 105 ambulances; and (c) the creation of refresher courses for health personnel in rural areas. The Third Plan proposes new policies, focusing on administrative reorganization of the health services, an idea which only vaguely appeared in the Second Plan. A topic which is shared in the three white papers is the claim of centralization and implicitly the creation of the mythical Ministrrio dr Sanidad [I l] which would coordinate preventive medicine (General Directorate of Health) and curative medicine (Seguridud Sociul). Centralization could also mean power over private practitioners, something that has been avoided for a long time. In any case, it is generally expected that such a ministry of health would finally fall under the control of the medical profession. The First Health P/m (29641967) is the most detailed and critical one. This critical standpoint gradually disappeared in the following Health Plans. Nevertheless, this First Health Plan is also the most limited one in its projections. The Comisariu dul PJm

recognized that “the broad tieid of preventive medicine exceeds the economic possibilities of one tirst plan of development” (1964: 58). The scope does not take into account the private sector. not planning any reform for private health services [12]. One ot the problems on which the three plans focus is mental health care services. The First Health Plan calls attention to the economic difficulties of the Patm~aro Nucionul de .-lsistewia PsiquiLifricrt (or PANAP) [ 131, The problem is “resolved” by the Diptrraciorws Procirrciuks which have different contracts with other institutions for the care of mental illness in their provinces, but the manifest lack of a budget in this sector is a major constraint against an adequate quality ol care [14]. The duplication of insurance is another problem mentioned in the First Health Plan. It estimates that 20”; of the population included in the SOE (the national health insurance) also have private health insurance or Sryu~o lihrr (Comisaria del Plan 1964:48). In summary, the First Health Plan is based on a considerable amount of data and (not very sophisticated) analysis, but nonetheless its decisions are based upon relatively unsupported judgments. The Second Health Plan (1968-1971) did not start until February 1969, due to the economic problems of 1967-68. It stresses regional development in contrast to the over-centralization of the First Plan. The tone of the Second Health Plan is less critical than the first. For example in spite of the obviously poor condition of the hospital facilities in the country the plan affirms: “Except for the hospitalization of mental patients. the present hospital facilities. with only a small increase, are capable (in reference to the number of beds) of meeting the necessities of the present population.” Nevertheless, the same report concludes: “The Spanish hospital care system invests little on the treatment of patients, which makes its efficiency low because the average stay per patient is very high. This is especially true in the case of psychiatric hospitals and not as much in general hospitals. Consequently many patients become physical or mental invalids who are a burden to the nation.” (Comisaria de1 Plan 1967:28,30). The low proportion of health personnel per bed allows the plan to affirm that the care is inexpensive, although inadequate. In summary. the Second Health Plan is based on some projections relative to the public sector, but if they were calculated in relation to the population size of the country they would represent actual retrocessions. The three main explicit objectives proposed by the Third Health Plun (1977-1975) are: (a) improvement of the medical care of the rural population. (b) coordination of hospital assistance and (c) regionalization of health services. The regionalization (or comurcalixcidn) follows the plans proposed by the General Directorate of Health. The present fifty Spanish provinces are divided into regions. varying from one to eighteen. In total there are 232 regions (comarcus) subdivided into sub-regions (suhcomarcus). These subregions include a population between 10000 and l2ooO inhabitants. no more than 20 km from the urban center. For the creation of all regional units. the Third Health Plan allocates a budget of 1400 million pesetas [ 151 during the four-year program, which is clearly insufficient for their minimal adequate implementation. We mentioned before that rural health

Spanish health planning experience: 19641975 was an objective of the Third Health Plan. Its criticism here is strong. referring to the low quality of facilities, and equipassistance, organization. ment [16]. The Third Health Plan also takes cognizance of the necessity of preventive medicine. but does not propose any concrete measure for this concern. The plan is the least concrete of all in this regard. It exposes (for the first time in health planning) a broad range of fashionable problems. including environmental health [ 173 and epidemiology [ 181, but it does not state any clear objectives or projections. The Third Health Plan is a “building plan” at a small scale. It proposes the remodelling of several buildings (Escuela National de Sanidad, J&was Provinciales de Sanidad. etc.), the creation of 15000 beds for

general purposes, 10000 beds for mental patients. and the “modernization” [19] of 7500 beds. These are the only concrete goals of the entire Plan. A typical lack of coordination can be seen in its budget. For the implementation of the program of regionalization of health services and the creation of health centers, the total expenditure of 1400 million pesetas is proposed. Overlapping with this project the Seyuridad Social plans to create outpatient clinics--outside the organization of the health centers-using for this purpose 12904 million pesetas. In addition to these, the military hospitals obtain a share of 2487 million pesetas, apparently more than proportional to their size. duplicating some of the previous services. In summary, the Third Health Plan is based on inappropriate and Table

1. Investments

of the national

Projections

Years 1963 plan 1964 1965 1966 1967 Second plan 1968 1969 1970 1971 Third plan 1972 1973 1974 1975

Total expenses (Million pesetas)

of the Health

Population covered (Thousands)

health

incomplete data and the (few) decisions and projections are not supported by analyses of the reality and/ or the study of alternatives. PROJECTIONS

Expenses per capita (Pesetas)

_

AND RESULTS

The first thing we notice in examining the Spanish health planning is that results have little to do with projections and vice versa. The tasks accomplished in previous plans are not recorded (probably not investigated), and consequently, the subsequent projections are rarely based on real data. We can demonstrate that there is little relatronship between reality and planning in the Spanish health case. In Table 1 we present the projected investments of the Seguridad Social (National Health Security) according to the three health plans, by year and the real investments that were later made. Projections, as can be noticed, were not made in reference to the total population and did not employ constant currency. Therefore the improvement is usually artificial. especially if we take into account three variables: (a) economic inflation during those years, 19641974; (b) population growth; and (c) the increase in the demand of health services. The investments proposed by the First Health Plan were an absolute minimum in order to obtain the stated goals (Comisaria de1 Plan 1964: 113). Unfortunately those investments are not clearly recorded in this white paper. The Second Health Plan projected a modest yearly increment of

(Seguridad

Social)

for the three first Spanish

health

plans

Results

Plans

15.000

First

security

453

Total expenses (Million pesetas)

(a) Population covered (Thousands)

Expenses per capita (Pesetas)

Proportion of population covered y;

Total Spanish population (Millions)

3.815 (b)

16,028

238

51

31.4

16,290 16,829 17,504 17.866

297 504 756 1.076

51 5’ 54 55

31.8 32.1 32.4 32.8

30.121 (c)

24.052

1.25’

4.842 (b) 8,486 (b) 13.226 (b) 19.230

32.002 34.607 36.562 38.534

25,393 27.066 27.797 28.614

1.260 1.279 1.315 1.347

23.529 29.817 44,059 56,738

18.060 19,061 21.358 23,194

1,303 1,564 2,063 2,446

55 57 63 68

33.1 33.5 33.8 34.1

29.794 30.806 32.004 33.148

2.098 2,499 2.840 3.135

76,333

23.586 -

3,236

68 -

34.5 34.8 (d) 35.1 (d) 35.5 (d)

62.523 76.986 90.886 103.929

(CJ (c) (cl (C)

-

Sources: Comisaria de1 Plan (1964:481. (1967:12.15). (1972:43.84). Amando De Miguel (1974: 150). Instituto National de Prevision (1967: 105). (1968: 1101. (1969: 133). (1970: 123), (1971: 147). (1972: 159). (1973:6.16.18.20). Notes: (a) This estimate includes all workers and their families of the Rdgimen General (asegurados and henejciarios). plus 95”. of the agrarian workers (non-owners or par cueiira ajrria) multiplied by 2.167 times, which is the average number of relatives per agrarian worker in 1972. The other 5”, do not pay dues and so they do not have health insurance. The formula is: 3.009 times the number the agrarian workers plus the number of the rigimerl general workers. (b) Includinp the agrarian branch and mutuality. (c) Including rehabilitation of invalids. (d) Our estimate.

JEWS M. DE MIGUEL

454 Table

2. Number

Projections

of the Health

Number

Years

First

1963 plan 1964 1965 1966 1967

Second plan 1968 1969 1970 1971 Third

plan 1972 1973 1974 1975

of beds according Plan

Rate per IO.000 population

Total beds

Mental patient beds

Total beds

157.565

33,600 (a)

50.2

139.383

39,329 (b)

138.040 142,268

39,540 (c) 39,329 (d)

Mental patient beds IO.7

144.814 42,382

169.814

to the three first Spanish

health plans _____

--__

Results ___Rate per 10.000 populatton --___---

Number

Total beds

Mental patient beds

156.819

39.358 (et

Mental Total patient beds beds --__--__-____ -19.4 12.5

Spamsh populatmn (Milhons)

3I4 3 I.8 .37. L 32.4 ‘7.X .t_

157.675 42.75 I

36.6

159,105

46.7

43.713

I26 12.8

33.1 .;j.5 33.x 33.I 34.5 34.x (n 35.1 (I) 35.5 (n

52.382 _-

Sources: Comisaria del Plan (1964:53.75,117). (1967:X$31), (1972:55,63). Direction General de Planificacion Social (1974). INE (1966: I). Notes: The arrows indicate the projections made by the Health Plans. (a) Estimate of the First Plan. (b) Provisional results of the Censo Hospitalario (Direction General de Sanidad 1966) according to the First Plan. It does not include 63 military hospitals. The same figures are given by the Second Plan as definitive results. (c) According to the Catdloyo de Hospitules (31 December 1966). (d) In reference to estimate (b) including establishments for the mentally retarded. drug addicts. and alcoholics. (e) The data pertain to. November 1963, although thev were published in the Crnso de Esarhkcirrrkwtos Surrrrmos

(INE 1966). ’ (fJ Our estimate.

the expenditures of the National Health Security between 6 and 7”/,. They expended much more than was planned; for example: 56738 million pesetas in 197 I compared to only 38 534 projected. Consequently, for the following year (1972) the plan projected an investment of 62523 million pesetas. Again this estimate was exceeded by the real expenditures, which were 76333 million pesetas [20]. We do not have data about future years (1973-75) but it is expected that the projections will be again of very low validity [2l]. In Table 2 we present the number of total beds in health establishments and its number for mental patients during 1963-1975. Here the dissonance between projection and results and the lack of appropriate planning is even clearer [22]. If we take into account the size of the Spanish population, the projections are every time lower. Speaking about the planning of hospital beds, both total and for mental patients, the FOESSA report (1970:787) states: “the Second Plan has not programmed any type of health development, but a certain stability, which on the whole means a clear retrocession”. In 1971 we observed (de Miguel and Oltra 1971: 19fT) thdt the hospital planning of the Second Health Plan did not project any progress if one takes into account popula-

tion growth. This relationship is demonstrated in Table 2 using this time the corrected population of the Census of 1970. Considering these population figures, projections of the First Health Plan change from 43.8 to 43.4 beds in health establishments. and from 12.4 to 12.0 mental patient beds, both per 10000 population. The Second Health Plan presents a similar decreasing trend in the number of total hospital beds: from 42.6 to 42.5. The situation on mental hospital planning is a little better than in the other health establishments, aithough the starting point is much lower. The total investment of the First Health Plan on the construction of mental health establishments is only three million pesetas for the four years (Comisaria de1 Plan 1964: 153); and it is totally dedicated to outpatient clinics (dispmsurios). The Second Health Plan calls attention to mental health as a pressing problem. mentioning several times the low proportion of beds in mental health establishments in the country. Nevertheless, this preoccupation is not reflected in the projections of the plan as can be observed in Table 2. In the same vein. the apparent preoccupation of the Second Health Plan for rural health is not reflected in suitable solutions. Table

2 demonstrates

the deficiencies

of health

data

Spanish health planning experience:

in Spain. There are no accurate data for beds in health establishments except for 1963 and 1970 [23]. In consequence. better methodological procedures usually “discover” more beds (both for mental and general patients) and consequently the results seem higher than the projections. This progress, of course. is artificial. THE PLANNING

MENTALITY

As Linz has pointed out, authoritarian regimes are based more on distinctive mentalitirs than on ideologies (1964: 301). This is particularly true at the level of institutions such as those of the socio-economic development plans. These mentalities are difficult to describe. but are a very valuable tool for the analysis of social structure. As the PAHSCENDES method states, planning is a state of mind rather than a method. In typical authoritarian regimes, a mentality is almost always connected to a lack of clear ideology. We present here some of the distinctive features of the health planning mentality in Spain and its lacking features. Contrary to what could be expected, the Health Plans tend to be praiseworthy descriptions of the situation, goals and efforts of the health sector, tending to ignore all the failures of the system and even of the previous planning processes. For example the First Health Plan summarizes: “Fortunately, in Spain health and social assistance are in a relatively advanced stage of development” (Comisaria de1 Plan 1964:47). The Third Health Plan calls the General Directorate of Health: “a function of notable efficacy” (Corn&aria de1 Plan 1972: 19). Both statements are difficult to accept. In addition to this, the Health Plans do not consider different alternatives for resolving the problems. and sometimes no action is taken in implementing the objectives. Referring to the mental patient, the three Health Plans can be fully considered as having an active role in the “labelling process”. In health planning, the assistance to mental patients is included as part of the social assistance program and not of the health program. This is due to the fact that for a long time mental health was considered a task for welfare institutions. In 1970. 487, of the beds for mental patients belonged to the Diputacionrs Provinciales and 27% to the Catholic Church; that is to say that three quarters of the total beds are under a welfare system and not a health system properly speaking. In fact. social assistance depends on the Direccih General de Benejcicwcia. while public health is taken care of by the Dirrccicirl Grr~rral de Sarridad. Both genera1 directorates. welfare and health, belong to the Ministerio de Gohrrnacicirl (Ministry of Interior). Nevertheless, social assistance includes. among other things, the care of the blind. mental patients, invalids and the mentally retarded. This reality is reflected in the attitudes of the Health Plans toward mental patients. invalids. and the mentally retarded [24]. Part of this mentality is reflected in the euphemisms that the Health Plans use when talking about mental patients and prostitutes [25]. Another consistent feature of the Health Plans is the bias of “misplaced concreteness” (Merton 1949). This can be interpreted as detailed description of non-

I%% I975

455

relevant data. For example, the First Plan presents data about all types [26] of health personnel working for the health establishments of the Seguridad Sociul, but there is no description of the number of doctors in private practice. or the number of patients they treat. The Third Health Plan presents detailed national costs of some infective diseases. but does not nay similar attention to the costs of health services bribe construction of health establishments [27]. The same kind of “misplaced concreteness” can be noticed in the language of the Health Plans. often obscured when necessary [28]. Last but not least. the mentality of the Health Plans is conservative [29]. This mentality contributes to the fact that the most important parts of the health planning process cannot be criticized, simply because they have not been written. It is widely recognized that the Spanish socio-economic plans have avoided the most important issues (such as the socio-political reorganization of the country). The FOESSA report affirms that “the documents of the Development Plans attack only superficial problems. leaving out the resolution of the most basic issues” (1970:302). In the case of health planning. the basic issues are: socialization of medicine. control of the private sector, equality of health care for the population. democratization of decision-making processes, study of health manpower and licensure trends, analysis of family planning (abortion. birth control). improvement of the quality of health care, control of the private sector. drug addiction, etc. At the level of the design of the Health Plans, there is absent; (a) a description of the expected results of the plan. (b) recommendations for activities or policies in other sectors. (c) use of general socio-economic guidelines, (d) estimates of expected social, cultural. and economic effects. (e) reference to political action and (f) concrete measures about the non-government sector. Let us mention here the six main lackings of the Spanish health planning process. (A) The Plans tend to ignore the private sector, both medical doctors and health establishments. Health is in an autarkic stage in Spain and private practice is still protected from outside competition and control. A study of the private practitioner should include : licensure trends, population covered and their health care costs, attitudes of the clientele and the quality of their care. power of the medical profession and associations of medical practitioners and interrelationships between private practice and the health system. (B) Related to this point is the lack of data and planning about concrete institutions, especially the Church. the military, and the pharmaceutical industry [30]. The role of the Church in the Spanish health system is still powerful, but it has not been studied by the present Health Plans. (C) Estimates of future requirements of health manpower. health education and health research (biomedical and environmental). are absent in the health planning process [3l]. These topics include all aspects of the socialization of the medical profession and health personnel. The importance of this aspect is illustrated by the observation that in 1970. 64”, of the total cost of the hospital system within the Seguridad Social was spent on health manpower personnel.

456

JESCS

,M.

(D) Quality of health care is a topic missing m the Spanish health planning process. The three white papers deal with the number of insured persons but rarely with the care they receive. No studies dealing with satisfaction. quality of health care services. quality of life. positive mental health. or other non-morbidity indicators of health are considered. (E) As a consequence of the conservative tone of the Health Plans. some of the most pressing problems are silenced, inainly the “sexual” and “political” ones. such as: abortion [32], birth control and family planning [33], socialization of medicine, democratization of the health sector and planning, social class differences and regional disequilibria. (F) Finally, the level of quantitative sophistication of the different Health Plans is extremely low [34]. There are no data about most of the topics [35]; and when there are such data, the plans do not quote the sources of information. The health planning process does not take into account the international available literature and research and theoretical references are the exception. Not only are data scarce. but they have little impact upon decision-making. Consequently, projections are not based on rational and accurate assessments of the existing situation. Except in a very few instances, there are no multivariate analyses (considering social class. regions. sex. age. urbanization). In addition, decisions of the Spanish Health Plans are based on common sense. ritualistic and/or intuitive behavior and demands from different pressure groups. There is a complete lack of a methodology and a model of health planning. THE HEALTH

PLANNING

EXPERIENCE

More than a decade of health planning experience has been completed in Spain. During this time. the Plans have tried to fill in some of the gaps in the health sector but it is not possible to speak about a global health plan for the country. The conclusions of the First Health Plan still seem true loday: “There does not exist in Spain an adequate organization or health facility for the full utilization of the available health manpower” (Comisaria del Plan 1964: 123). The forecast of the FOESSA report (1970:787) was that in 1971 Spain would face “a hospital structure that would be one of the most deficient in Europe”. It is widely accepted that the main failures of the health plans can be resolved. For this purpose it would be essential to state the results of every health plan. mentioning also the failures of the projections and goals [36]. In addition it would be necessary to include in the health planning process the objectlves of the general socio-economic plans. especially the main objective of the reduction of regional and class disequilibria [37]. Much of the health reform in Spain at present is concretized in endless discussions about ministerial reorganization. This includes (a) the desire to resolve the imbalance of resources between the social sccurity. General Directorate of Health, and other institutions; and (b) the creation of a Ministry of Health. There are no rational considerations behind either issue. The creation of a Mini.stc,rio de Sar~idad, implicit in the Health Plans. is defended by both leftist and

IE

MIGCFL

rightist forces. in the hope of acquirmg power through the leadership of this new department and more administrative centralization. Generally speaking. the selection of projections and obJectives is based on political considerations. because it decides which ideologies. mentalities or slmpl\ values. should be followed. In this sense. Spanish health planning does not make many political decisions. thus redu&g the scope of its plans to present technical goals. which do not resolve any of the important problems. We can even atfirm that the Spanish health planners are afraid of reaching any political decision. Who would benefit from these Plans’! The Health Plans and their investment projections can be seen as a sharing of profits among the diflerent pressure and interest groups within the health sector. The medical profession is not mentioned. discussed. or planned for in any of the three white papers. In doing so. the Interests of this social group remain untouched. The same can be said of the pharmaceutical industry. the Church. etc. In an article published b> Ruedo Ibirico Press which considers the First Plan. the author asks: “How can a plan be democratic if the political system in which the plan is born and it starts has not the most elementary features of a democratic system?” (Garcia 1966:27). The paradox is that f/le Sparris/l HL’L&/IPhs me kss unfhorituricfr~ thr~ tlw wgimc. This is partially due to the fact that the plans were written by “technocrats” and not b> “politicos”. A widely accepted opinion is that a solution would be the creation of a more effective. knowledgeable. and democratic commission for the Health Plans. A better planning of the health sector would need ten-year projections: an appropriate socialization of the health system would ask for long-term projections. In spite of a decade of health planning experience. Spain has not yet developed any health reform. not even the rcgionalization of health services. According to these Facts the health system still remains in a highly unequal and discriminating form for the people of the country. REFERE\ICES I. The starting point of the Spamsh socio-rconomlc plans was the report of a mission organized by the International Bank for Reconstruction and Development on 7-/w Ecowwrc Dwltlqvno~r o/ Sptri,~ ( 1Yh?). usually called the Ci’or/tl Btr~h Rt,pwt. No mrntlon was made m this report about the health sector. A critique of the World Bank Report appeared in Spam the same year. published bq Rcvista de Occidents (Edited by Enrique Fuentcs Quintana. ‘I Yhi). ’ For more details see OECD (1972). ?: See. for cxamplc Amando De Miguel in FOESSA (1070: 177 304) (lY73a: I?’ 257 and 1974~: 13 127); Tamames (lY671; and Prados -2rrarte (1968). 4. Therefore. thr commission is not responsible to any constttucncq. It has no elaborated and guiding ideolog). but rather “distinctive mentalities.” as Lmz suggested in his definition of an authoritarian regime (lYM:397). In Spain planners and those who carry out policies arc man> times the same persons. The plans arc deslgncd by the Plerrlc~~cru &[ Gohirrno (or b! the .%~i~tiarwro c/v P /tr,rific,uc,icjrr &I Dc.surro//r, in the cast: of the fourth and following plans). The planning committees arc usually chaIred hq a high CIVII servant.

Spanish

5

6

7

8

9

10.

-

First Plan Second Plan Third Plan

-

planning

In the First Health Plan the prcsidcnt was Antonm Carro Martinez (presently Mifli.srrcrSuhsc,~r~,furio dc la Presidervia de/ Gohic,rw); in the Second Health Plan, Jose L. Villar Palasi (ex-minister of Education): and in the Third Plan. Enrique Mata Gorostizaga (high officer in the Ministry of Labor and one of the names for the post of Minister of Health). This stage of drsarrollisrno has been summarized by OItra and Salcedo (I 973: X8-96) in an article about the relationship between statistics and ideology in Spain. The World Bank Report stated: “The most appropriate type of planning at this juncture in Spain is ‘indicative’ planning. Under this kind of planning. the Government does not attempt to order every aspect of economic life. Its role is rather: (a) to propose a rate of growth for the economy as a whole and work out the implications of the proposal for the principal economic magnitudes and for the growth of the principal sectors: (b) to state the actions it proposes as a consequence. to take in respect to its economic policies toward both the public and private sectors and to those investments for which it is responsible in order to achieve and sustain the indicated rate of growth.” (International Bank for Reconstruction and Development 1963 : 3-4). For a commentary on this topic see Aceves (1973:93fT). It is interesting to note that many democratic countries utilize more coercion in their Health Plans than those of an authoritarian country such as Spain, “This lack of planning machinery is in general due to the fact that the health sector is not assigned high priority in schemes for economic development.” (Bridgman and Roemer 1973: 173). A suggestive article about the relative importance of plans which stress social concerns is presented by Leopold0 Arranz (1972). The three are published by the Cornisaria de/ Ph dr Desarrollo Ecmh~iro !’ Social of the Prrsidencia de/ Gohirrno. in 1964. 1967 and 1972. They are entitled: Srguridad Soc,ial. Smidad. J’ Asistcwcia Socrol. The membership of the commission is inversely related to the size of the report. as can be seen by these. figures: Number of pages of the Health Plan:

-

health

II6 21 21

Number of members in the health commission: -27 9.5 1x9

of the Mhistcrio dc I1 The polemic about the creation Smrdud is as long as it is undocumented. No group has described the guidelines for such an institution and there is no articulated plannmg about what would be done by it and hon. We believe these discussions are mainly about political power but not actually health reform. For a more detailed account of this polemic bei‘ Tr~hrrrr ,\IL;dicu. 12 The first Health Plan points out: “In the health sector only public investments have been established. It cannot be left to private initiative to decide whether or not to create the necessar! estabhshments for the formation of basic health facilities that would allow us to be responsible for national health care”. (Comisaria del Plan 1964: 1110. I 7 “The fight against mental illness is led by the Potromro .Z’NCIOIIN/ 11~~ .A.slstrwcm Psiyui4tricu [PANAP]. which cannot accomplish its function of coordination of this sector. nor the direct functions of health care. because of the lack of economic resources” (Comisaria de1 Plan 1961: 87). See also Serigo and Porras (1966).

experience:

457

1964-1975

14. “It is important to note that the Diputacioncs Prooirlciales hire beds in health establishments of the Church. private sector or the State, although the reduced amount of money contributed per patient per day (about 25 pesetas) does not allow for efficient assistance” (Comisaria de1 Plan 1964:5). 15. The prices for foreign pesetas (selling banknotes) as quoted the January 2, of every year (at 4:00 p.m.. eastern time) in U.S. dollars are: -Years

Dollars

per peseta

_ 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 (From T/K, Wall Street

0.166 0. I695 0.170 0.170 0.170 0150 0.145 0.143 0.143 0.155 0.165 0. I 80 Jourml)

16 The Third Plan is rather conscious of all these problems: “( 1) The rural population does not receive satisfactory health assistance. Usually rural people have to g--many times great distances--to the important centers of population to ask for a simple test. or for other more complete assistance. (2) The organization and the functional system have remained oldfashioned and insufficient to accommodate the present problems of the population. (3) The medical doctors in charge of this important public service lack the necessary installations and the technical equipment in order to accomplish their task with efficacy. The consequence is the scant stimulus that the rural stratum offers to the health personnel.” (Comisaria de1 Plan 1972:52). 17. This term is translated as ambirnte ecoldgico (i.e. ecological ambient). an expression full of cryptic meanings, ranging from “virus research” to “housing”. 18. We doubt that “epidemiological research” was properly understood by the commission. For example. they propose “methodological and epidemiological studies coordinating the specific activities mentioned. and its relation to the epidemiological condition of the country at present, including chronic or non-transmissible diseases” (Comisaria de1 Plan 1972:48). 19 The terms used are “reform. modernization, and raising.” (Comisaria de1 Plan 1972:56). without giving more details about the way in which the money will be spent. 20 An explanation for these failures is that the cost of drugs changes in a market (non-socialized) situation. Referring to 1970. the Third Health Plan emphasizes that the cost of drugs is 46% of the total cost of health services within the national health security system. If the cost of drugs is not controlled in the future. it will be difficult to design accurate projections of costs (See Comisaria de1 Plan 1972:26). On the other hand. the pharmaceutical industry in Spain has been strongly criticized. due to its lack of research and its fantastic profits (See also note 30). 21 In addition. it should be noted that the Seguridad Socral is a mutualist organization not led by its own members (Ribera 1974: 124). Consequently. plans of investment would be directed toward different interests than those of the insured population.

-15X

JESUS M. DE MIGL:EL

22. Nevertheless. the Second Health Plan is conscious of the elasticity of the health services demanded: “In this sector. the supply creates its own demand. that is to say. there will be a higher population demand-previously reluctant to use the hospitals-in proportlon to the higher level of hospital assistance” (Comisaria de1 Plan 1967:ZS). 23 The different Health Plans call attention to the necessity of improving the quality and quantity of health statistics in the country. It is true that the Spanish health plans are difficult to design due to the lack of appropriate data. For example. there are only two censuses of health establishments made by the Insriruto :VncionuI dc Estadisticu. one in 1949 and the other in 1964 (Instituto National de Estadistica 1952: 1966). The data of the latter census pertains to November 1963. but it was not published until 1966. 24 For example. the Second Health Plan recognizes that 7.5”, of minors under the control of the Ohra de Prorrccidn de Merrores were psychopaths or subnormals (1967:54). On some occasions. the Health Plans tend to include mental patients in the same group with prostitutes. mentally retarded persons. homosexuals. alcoholics, drug addicts. etc (See Comisaria del Plan 1964: 106). 25 “It is expected that economic development will produce an increase in the number of young girls in moral danger [sic] and that they should have to be protected, by measures of social aid” (Comisaria del Plan 1964: I I?). 26 This description includes: janitors. gardeners, chaplains. barbers. servants. seamstresses, operators. draftsmen, watchmakers, hotones. serenos, mozos de rrutop.sius. encaryados

27

28

79.

30

dr corrros,

mujerrs

dr la limpirza.

etc (Comisaria del Plan 1964: 144ff). The Third Health Plan presents in its appendices (Comisaria del Plan 1972:85-95) the calculations of the monetary losses due to deaths by poliomyelitis, diphtheria. tetanus. whooping cough and typhoid fever, supposing that these persons were going to live the average life expectancy (70 yr) and to produce 8 I7 dollars of GNP per year. The calculation is made in each case from the year the patient dies even in the case of infants. Obviously. these figures are irrelevant in a health planning process. .As an example. the Second Health Plan views epidemiological research as: “Necessary analysis to accomplish the subsequent survey to the appearance of index cases, and also the practice of prospective and retrospective studies.” (sic) (Comisaria del Plan 1967:44). Other examples of this misuse of language are in Comisaria del Plan (1964:97). Speaking of another authoritarlan regime (Portugal) Cravinho (I971 : 101) also mentioned “the lack of clarification of the objecttves” and the nrhulosidadr of goals and proJections of the Portuguese socio-economic plans. This matches the reality of a country that has the lowest proportion of female doctors in all Europe. This tone is also exemplified by the following quote: “If the problem of invalids did not become manifest in Spain after the Gurrru de L~herocidn with the same intensity as in the other countries after the last World War. it was because our economy was totally destroyed. wlthout our own resources and without foreign and: our national reconstruction did not need the work of invalids. but during the first years of our resurgence. thcrc had been an excess of physically normal workers. and even skilled workers. It does not mean that there was not a problem of invalids; on the contrary. our war produced nearly a million physically defective persons” (Comisaria del Plan 1964:9X). Set Roldan (1966). The report of the FRAP (F,o~rc, RI,r,o[trcrr,rrclrto .Anti/tr,sc~i.stu y Prrtrititico) of the PCE-

31.

32.

33.

34. 35.

36.

ML (Parrido Comun~srtr Espcuioi .Lfcrr\-rstu Lc,rrurl,ru~ concerning the financing of social securit! state\: “Pharmaceutical products are the great source of puhlicity for the Seguridnd SociLli. and the only sector ot the expenditures in which the social securlt) 1s generous to the workers: even so this favors the pharmaceutical firms more than the workers” ( 197-1: 7). Only the First Health Plan presents some data about health manpower. but there are no objectives nor projections. In Spain the abortos statistics generally refers to mlscarriages or involuntary fetal deaths. There are no rcllable statistics about abortion. To the contrary. the Health Plans include some “protection to the family” programs. paying a certam amount of money to couples that get married and women that give birth to (legitimate) children. Plans are intuitively generated. Techmques such ~,IC PERT. CPM. PPBS. etc.. are totally absent. In reference to the Spanish Health Plans. we would state the following rule: “The more important the topic the less data.” This is done in Portugal. The Gabinrtr de Estudos e Planeamento of the MinistPrio de Saildr e Asslstcncia (1971 : 1972) publishes yearly a Rchttim t/c,EU,UI-

~Liodo 111Piano

dr Fomento.

37. This has been suggested hy Tamames Miguel and Salcedo (1972).

(1968) and

De

BIBLIOGRAPHY Anderson, Spain:

Charles

W. The Polirlcul

Policy-Making

Eco~otny

in an Authoritarian

q/ .Modrrn Country. The

University of Wisconsin Press. Madison. 1970. Arranz. Leopoldo. El presupuesto socral en una sociedad en desarrollo. Reoista Iheroamrricunu dc Sequridnd Social. Vol. 5. 1972. Bridgman, R. F. and Roemer. M. 1. Hosprtcll Lcgisiutum und Hosoital Svstrms. WHO. Geneva. 1973. Comisaria del Plan de Desarrollo Econ6mico 4 Social. I. Anexo al Plan de Desarrollo Econbmico y Soctal. Adios 1964 a 1967: Obras y Servicios de las Corporaciones Locales. Sanidad y Asistencia Social. Presidencia del Gobierno. Madrih. 1964. II. Plan de Desarrollo Econbmico v Social: Seeurldad Social. Sanidad y Asistencia Social. Presiden:ia del Gobierno. Madrid. 1967. III. Plan de Desarrollo Econbmico y Social: Segurldad Social. Sanidad y Asistencia Social. Presidencia. del Gobierno. Madrid. 1972. Cravinho. Joiio. FundamentaCjo das decisoes de planeamento em Portugal. In 0 drs~,lrol~irnt,rlt[~ rm Portuyui: .4spectos sociais e irlstituciorlais (Edited by Nunes. .A. Sedas) pp. 96-122. Gabinete de Insvestigayoes Socials. Lisbon, 197 I. De Miguel, Amando. Manual de estructura social de Espafia. Tecnos. Madrid. 1974a. Yo. critico. Edicusa. Madrid, 1974b. De Miguel, Amando and Salcedo. Juan. Din&mica del desarrollo industrial de las regiones espafiolas. Tecnos. Madrid. 1972. De Miguel, Jesus M. and Oltra. Benjamin J. Para una sociologia de la salud mental en Espaiia. Revlsta Espaiiola de la Opinicin Ptiblica. Vol. 24. 1971 Direccibn General de Planificacirjn Social. Notas sobrc el equipamiento sanitario en Espafia. Madrtd: Servlcio de Estratrficaci& y Movilidad Social (mimeo). 1974. Direccitin General de-Sanidad. Catilogo de Hospitales. Ministerio de Gohernacitin. Madrid. 1966. FOESSA. Estudio sociolbgico sobre la situaci6n social de Esparia 1970. Euramirica. Madnd. 1970.

Spanish health planning experience: Frente Revolucionario Antifascista y Patriotic0 (FRAP) Financiacion de la Seguridad Social. Madrid (mimeo). 1974. Garcia. C. E. Q. De la autarquia economica al Plan de Desarrollo: Veinticinco atios de economia espaiiola. Horizonte Espanol (Edited by Aboy. Ramon ct nl.) pp. 13-46 Vol. 1. Ruedo Iberico, Paris. 1966. Hilleboe. Herman E.. Barkhuus. Arne and Thomas. William C. Approaches to National Health Planning. WHO. Geneva. (Public Health Papers, No. 46). 1972. Instituto National de Estadistica (INE). Censo de establecimientos sanitarios y benefices. Referido al dia primero de noviembre de 1949. INE. Madrid. 1972. Censo de Establecimientos Sanitarios: Aiio 1966. INE. Madrid. 1966. Instituto National de Prevision (INP). Memoria estadistica de 10s seguros sociales administrados por el INP: Aiio 1966. INP. Madrid. 1967. Memoria estadistica de las contingencias de la seguridad social admmistradas por el INP: Ano 1967. INP. Madrid, 1968. Memoria estadistica de las contingencias de la seguridad social administradas por el INP: Ano 1968. INP. Madrid. 1969. Memoria estadistica de las contingencias de la seguridad social administradas por el INP: Ario 1969. INP. Madrid. 1970.

19641975

459

Memoria estadistica de las contingencias de la seguridad social administradas por el INP: Afro 1970. INP, Madrid. 1971. Memoria estadistica de las contingencias de la seguridad social administradas por el INP: Atio 1971. INP. Madrid, 1972. Memoria estadistica de las contingencias de la seguridad social administradas por el INP: Ario 1967. INP. Madrid. 1973. International Bank for Reconstruction and Development (World Bank). The Economic Development of’ Spain. Johns Hopkins, Baltimore. 1963. Linz, Juan J. An authoritarian regime: Spain. In Clraouges, ideologies and Party Systems (Edited by Allardt, E. and Littunen. Y.) pp. 291-341. Transactions of the Westermarck Society, Helsinki, 1964. Merton, Robert K. Social Theory and Social Structure. Free Press. Glencoe. Illinois. 1949. Ministerio da Saude e Assistencia. Relatorio de Execucao do III Plano de Fomento. Gabinete de Estudos e Planeamento. Lisbon. 1971. Relatorio de Execucao do III Plano de Fomento. Gabinete de Estudos e Planeamento, Lisbon, 1972. Mott. Basil J. F. Politics and international planning, Sot. Sci. Med. 8. 271-274.

1974.