The case of Spain

Health Polky, 15 (1990) llQ-142 Elsevier

119

Chapter 5

The case of Spain Josep A. Rodriguez and Jesus M. de Miguel

Introduction The main characteristics of the Spanish professional market can be defined by a clear public supremacy (the State) and the building of an organized medicine. The Spanish medical profession is employed in large complex organizations and depends directly from the State for its existence. The development of the Social Security (INSALUD) health care structure gives shape to a peculiar professional market for the 121000 (in 1984) Spanish doctors. The construction of Social Security/lNSALUD means the direct implication of the State as the main provider of medical services for wide areas of the population (productive ones), competing directly with the private sector (the traditional provider of certain medical services for the upper classes) and the local public sector (which offers social charitable medical services). For forty years Spain has been under a dictatorship (an authoritarian regime) thus having a discordant political system with respect to the rest of western countries. In 1977 Spain got a democratic system and the following year a new Constitution (monarchical and parliamentary). The present political regime has the characteristics of a pluralistic democratic system but its youth has obstructed the stability of its political interest which still causes frequent formation and dissolution of political formations. From 1977 to 1982 the - now extinct - Unibn de1 Centro Democrcitico (UCD), ruled the country having the Partido Socialista Obrero Espariol (PSOE) as a very powerful opposition. In 1982 the UCD’s self-destruction gave the PSOE access to power and since then it has had an absolute majority in parliament. The most important public health legacy of the Franc0 dictatorship is that it produced an irreversible social fact: the general idea that medical assistance is a right for the whole population, and that the State is ultimately responsible for the citizens and the community health level. Spain produced a peculiar health care sector: the Franc0 regime created a kind of ‘national health service’ which later was extended and shaped as the National Health System by the socialists. Spain is a clear example of the early creation of a public health care sector, however, with an incomplete and slow development. In the eighties, medical assistance covered almost the totality of the population. Nevertheless, Spain is an unusual case in the 0168-8510/90/$03.500

1990 Elsevier Science Publishers

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B.V. (Biomedical

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context of Europe, with a high rate of physicians (but with a high rate of medical unemployment and part-time jobs) and one of the lowest rates of hospital beds (with many low-quality beds or in inappropriate buildings). It is also highly disorganized and there is an irregular use of public medical means with private objectives. In spite of all that, Spain has an enviable general health among the population, with a high life expectancy and low child mortality. The years of socialist government are characterized by a constant debate and conflict between the Administration, with its reformist projects, and the profession, with its adaptation and survival projects. The basic debates between the State and the profession are centered in (1) the detinition of the shape and limits of the health care model; (2) the characteristics of professional practice in this model; (3) the control over the organization of professional work; (4) professional status, and (5) the professional supply.

The health care system The contemporary public health system started during the post civil war period, in 1942, with the creation of a Seguro Obligaturio de Enfermadad (SOE) - Compulsory National Health Insurance - and was completed half a century afterwards (in 1988) when the by General de Sanidad (LGS) - National Health Care Act starts to develop and articulates the Sisrema Nacionaf de Salud (SNS) - National Health System. This long process meant the development of a public system to assist all the population. The laws and political changes of the last decades can be clustered into five periods: post-war (from 1939 to 1966), expansion (from 1967 to 1975), democratization (between 1976 and 1981), first socialist government (1982 to 1986), and the health care reform started in 1987. A list of the most important laws and reforms of the century can be found in Appendix A. The first period, the post-war, starts from the creation of the Seguro Obligatorio de Enfermaakd to the first reform of the public health system embodied in the Ley de Bases de la Seguridad Social - Social Security Act. It is a long period in which the central public sector (Social Security) slowly grows at the expense of the local health administration (basically Town Halls and Provincial Governments) to finally offer medical assistance to 50% of the population. The original model designed to protect only the industrial workers is transformed into a model that covers all manual workers, then general employees, and it finally aspires to reach the middle-class. The medical professional model (as well as those of the other care professions and occupations) appears dominated by the Ministeriu de Gobernacibn (Ministry of the Interior) from which all the health care matters depended in the very first period. The second period starts with the Social Security reform and goes on until France’s death in November of 1975. The health care model is already clearly universalist and adopts a pattern of centralized development based on the deterioration of the regional public administration, which is itself locally decentralized. The first half of the sixties shows an enormous expansion of the public hospital system, of

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building, and of employing health care workers, mainly physicians. These were optimistic times, in spite of the political uncertainty during the last years of the Franc0 era. France’s death meant that various attempts were made regarding the democratization of the public health care sector, the health care professions, and the system of Professional Associations. But between 1976 and 1981 (right up to the socialists coming to power) the reforms became chronic and were never applied. An Interministerial Commission for the health care reform was even created but no substantial reform was made and France’s health care system was continued, although it maintained a high level of disorganization and irregular functioning. The socialist government in its first four years, from 1982 to 1986, suffered a similar evolution. First they tried to totally change the health care model of Social Security, and after four years of attempts they decided to keep it, widening its coverage and somewhat decentralizing its structure. The process was weakening for the socialist party that had to fight against an organized and belligerent medical profession. The National Health Care System was not created until the end of the first socialist government, in 1987. From its early days onwards in 1983, the health care reform has systematically been questioned and attacked by the highly organized medical profession. A confrontation seemed inevitable and in 1987 the medical profession and the hospital doctors organize a series of strikes and conflicts that are probably the most serious in the whole century with regard to this sector. While the medical profession could not oppose the original outline of the SOE, half a century later the democratic political system allowed them to articulate its opposition to the expansion and strenghtening of this health care model. The development of the Spanish medical profession is closely related to the development model of what Larson [21] and Starr [41] have defined as medical/health care market. We can divide the Spanish health care market of the last decades in three main periods. In the first period, from the end of the civil war to 1963/64, the medical market can be considered as autarchic as is the rest of the Spanish society. The private market is limited, the majority of the population does not have enough economic resources to face its medical needs, and the charitable-public health assistance is small. The Spanish society of that period is not able to generate enough demand to develop the medical-health market nor the medical profession. The creation of the Seguro Obligatorio de Enfermudhd (1944) changes the main features of the medical-health market (and, therefore, of the health services and the medical profession itself). It is the first step for the building of a medical-health market controlled by the State. From that very moment the State undertakes the creation of a large public health care system that limits the possibilities (already scarce) for the development of a private system. Until 1963, although the SOE already covered half of the population, the public health system leaves out such important areas as hospital medicine. That situation allows a certain development in the private hospital market, which indirectly benefits from the rise in health care demand due to the expansion of the SOE, and satisfies the health care needs of the wealthier classes. The less privileged social groups are deprived of the most modem medical health services. 1471

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In the secondperiod, from 1963 to 1975, the public health care system was built and the preponderance of the public sector over the private sector was established. Those are the years in which the large hospitals were constructed and the Social Security medicine was spread among Spanish population. The covering of Social Security goes from 50% of the population in 1963, to 77% in 1975 and 92% in 1984. From that year onwards almost the entire population has a practically free access to the public health care system. Thus, it is a medical-health care market whose main features and parameters are defined by the State. The supply of health care services was conditioned by the development of the Social Security system; while the health care demand holds a narrow relationship with the extension of the SOE. The third period, from 1976 to 1988, is marked by the economic crisis of the Welfare State. Those are the first years of the democratic system with the consequent changes both in the health policy models and in their elaboration process. Initially, until 1982, there are several attempts to fix the complexity and chaos prevailing in the health care system with a reduction in the public sector and allowing the private sector to develop [37]. In spite of the fact that the right to Social Security health care services reaches more than 92% of the population, the growth in the public system is restrained, especially in the hospital sector. The objectives of the first socialist government (1982-86) are the rationalization and strenghtening of the public system, while trying at the same time to reduce the growth in health care expenses. A period of low growth, characterized by the remodelling of the entire health system, is then started. As can be observed in Table 1 the medical profession development model is closely tied to the construction of the health care system. The creation of the SOE (1944) means the progressive incorporation of the medical profession into the service of the State, in such a way that in 1963 Social Security employs 68% of the profession. Nevertheless, the early weak dynamics of the medical market do not produce great expectations, or a high professional demand. The number of professionals between 1949 and 1963 increases only by 9000. Since 1963, with the approval of the Ley de Buses de la Seguridud Social (Social Security Act), the great expansion of the hospital system (which had its main motor in the public and Social Security hospital sector) generates a high demand of professionals, considerably increasing the professionals’ expectations. The proportion of the profession working for the Social Security goes from 68% in 1963 to 84% in 1975; the hospitals are the organizations that progressively gather professional resources: from 30% in 1949 to 65% in 1975. This situation forces the formation of new physicians, preferably in hospital specialties. Thus, the number of students doubled between 1972 and 1975 (see Table 2). The expectations of the professional market are so great that in 1975 the number of medical students is higher than the number of practising physicians. The expansion of the public health care system absorbs most of the profession and gives cause for an accelerated increase in the number of professionals [37]. The professional market parameters suffer a reduction from 1975 on. The health care system stopped growing and even more so the hospital system which had employed at one point 65% of the profession. As a consequence, the professional I481

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Table 1 Evolution of 1he structure

of the medical profession

Physicians Physicians per thousand inhabitants Physicians per thousand beds Number of beds Social Security beds Social Security beds (%) For-profit beds (%) Hospital doctors (%) Doctors per hundred medical students Physicians in Social Security (%) Specialists in Social Security (%) Population covered by Social security (%)

1949

1963

1972

1975

1981

1984

28931

37 743

49 256

54533

96 569

121362

85* 69 127 343 3 677 2.9 18.6 30.5 229

119 85 156819 14223 9.1 21.0 32.2 225

141 153 177 385 33 066 18.7 14.3 48.1 128

148 219 19044 41406 21.7 15.6 65.0 78

256 252 202 969 53473 26.3 18.7 45.1 145

320 206 567 57000 -

-

67.8

70.2

83.5

59.0

44.0

-

45.4

56.4

64.0

67.0

67.0

-

50

61

77

83

92

226

Sources: INE, Anuurio Estadistico de Espaiia 1984 (Madrid: INE, 1985). INE, Estadfsticu de establecimientos sanitarios (Madrid: INE, several years). Ministerio de Trabajo, Libra bhco de la Seguridad Social (Madrid: Subsecretaria de la Seguridad Social, 1977), pp. 543-544. INSALUD, Ir$orme eco&mico funcional de lnr instituciones sanitaries 1984 (Madrid: INSALUD, 1986). *1943 Table 2 Medical studies 1950

Number of students 12628 Students/100 000 inhabitants 44.1 Female students (%) 2.8 First year students (%) 16.0 Medical students from total university students (%) 23.5 Medical graduates from total university graduates (%) 19.8 Students per teacher 21.5 Ratio Medical Schools students per Law students

1960

1970

1980

1983

15 986 52.5 !:Z

31011 91.1 21.0 35.2

79 165 210.0 41.0 14.4

59 588 (150.4) 45.9 12.2

19.8

16.1

17.2

11.7

25.8 10.9

20.9 13.6

20.5 15.2

27.4 10.6

-

(1.56)

0.99

0.59

Sources: INE, Estadlstica de la ensetianza en Espaiia: Curses 1949-19.50; 19594960; 1969-1970; 1979-1980; 1982-1983 (Madrid: INE, several years).

demand becomes stable. Given the fact that the production of new physicians is high (its number doubles between 1975 and 1983), not only the number of professionals working directly for the Social Security (INSALUD) is reduced - goes from 84% in 1975 to less than 55% in 1983 - but employment for the new professionals is growing scarce. These new professionals, socialized to work for the public system and in hospital settings, must face a health care market that now tries to reduce its ex1491

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penses, limiting the professional demand and the development of the hospital sector. Nowadays there are more than 121000 physicians in the country and a little less than 60000 students. For years the number of students was superior to the number of professionals, but from the beginning of the eighties that phenomenon started to change, and in 1984 the number of professionals was practically double the number of students. Between 1953 and 1984 the number of physicians increased four times (the largest increase since 1977 when the number was doubled) and the number of students five times.

Medical manpower policy The establishment of an autoritarian political regime after the civil war meant for the medical profession the beginning of radical changes in its organization, practice and professional characteristics; to a point that there is a practically total change in the main parameters of the profession. Francoism means the end of associationism experiences - and also of political independence - developed during the previous decades, as well as the cooption and political neutralization of the profession. In 1945, with the By-laws of the Official Medical Association the Consejo General de Colegios M6dico.s de Espatia - the Medical Association Council - (created in 1925) is transformed into a basic tool for the political control of a group known for its capability of influence and political manoeuvring, besides its historical relations with the upper social classes. Control over the profession is obtained by affiliating into the centralized and highly authoritarian structure of Provincial Associations, which is compulsory when one wants to practice the profession. Medical Associations become ‘official’, and the management is appointed by the Government, thus, political control is secured. Associations are, then, turned into political-administrative appendixes of the State. The relationship between the Official Medical Associations and the State takes a clearly corporative shape, for they have the ability and legitimacy to represent the whole professional group, and in exchange for their political dependency they obtain a high level of delegated political power. An authoritarian political control makes it possible for the opposition to the Seguro Obligutorio de Enfermadud (Compulsory Health Insurance) to be counteracted, and at the same time it secures a massive participation. This way the State starts its health care growth, defining and controlling the health care market and, as a consequence, the practice of the profession, The increasing dependence of the profession on the State (and its medical market) transforms the main characteristics of professional practice, which is progressively employed and ofticialized (transformed into civil servants), and reduces its last power over the organization of its work and over the determination where their patients are to be treated. However, their collaboration in the construction of a new public sector (SOE-SS) offers the medical profession tremendous possibilities for its expansion and for its economic and social strengthening. The medical profession progressively accommodates itself to the immediate

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benefits obtained with the expansion of Social Security - and the consequent growth in the demand for its services - in spite of its existence and future being left completely in the hands of the State. For years - precisely the years of its expansion - Social Security has offered more work than the professionals are able to perform. Nevertheless, the profession itself loses control over the supply and demand of professionals. It all depends directly on the State, which does not at all try to rationally plan professional resources. The State becomes the great medical entrepreneur; at the moment the INSALUD employs 50% of the Spanish medical profession. If we add the physicians who work for the rest of the public sector, the State is the direct job provider for two-thirds of the medical profession (see Table 3). The dependence of the profession is even greater - to 80% - if we include the professionals whose work depends directly on service contracts (conciertos) between INSALUD and other providers of medical services [37]. Table 3 Professional

activity according

to ownership

of the health care Institution,

1993

INSALUD

Rest of public sector

Private sector

Total

Hospital (%) Primary health care (%) Total (%)

33 67 100

83 17 100

53 47 100

46 43 100*

Physicians from the total of professionals (%)

48

18

23

100*

Sources: INE. Anuario Esfadiskx de Espwh 1984 (Madrid: INE, 1985). INE, Estadfstica de inslituciones m&arias 1983 (Madrid: INE. 1986). *To complete the data it is necessary to include 10% of unemployed physicians.

The most direct consequence of their dependence on the State for their subsistence is their progressive transformation into public employees (civil servants). This tendency has sharpened over the last decade, with the reforms undertaken by the socialist party in power. The health care structure is considered as a natural extension of the State administration. The socialist government also attempts to apply the State bureaucratic rationality into the health care dynamics, changing the contractual relationship with the profession into a public employee/civil servant relationship (as the State’s employees). The development of organized medicine produces substantial changes in the professional parameters. The last tifty years have witnessed a complete transformation in the medical-health care market and in the role of the medical profession. It moves from medicine practised in a liberal way to health care as the product of complex organizations that use the services of several health professionals (physicians among them). Hospitals have become the central organizations in the provision of health care services, and directly employ and organize the work of almost half the profession. Of the 43% professionals working in Primary Health Care, approximately half also work in organized structures (although with high ‘anarchy’ levels): Outpatient WI

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Services (Ambuluzorius) and Primary Care Centers (Centros de Sal&). The traditional practice of medicine, the one in which there is a direct contractual doctor patient relationship, becomes less than a fifth of the total professional market. The supremacy of a highly organized health care and the control of the State over the medical market are the main axis around which the professional practice turns in the eighties. Half of the professionals have at least two jobs while, at the same time, the unemployment rate is rather high (10% in 1983; 20% in 1987). 96% of the medical profession sells its services to health care organizations as employees, while 40% of them also practise medicine on their own; and only 13% practices medicine in cooperation with other professionals or associated to some private insurance plan (see Table 4). Almost the entire profession (97% of the professionals) offers its services through public organizations while only 24% does so in private organizations, basically the for-profit type. Table 4 The professional

practice

in 1993

Total Type of practice Solo practice (%) Associated to an Insurance Plan In cooperation with other physicians Employee: - Substitute - Temporary - Unlimited contract - Tenure position Type of center Hospital Ambulatory Private Office Institutional

Main job

Second job

39.7 10.0 2.6

20.0

36.0

3.0 1.1

12.6 1.7

3.0 20.0

0.1 5.8

6;::

2.5 18.5 6.3 48.5

345

50.3 44.5 47.0

43.2 30.9 24.9

16.9 30.0 50.0

68.0 8.5 10.2 5.4 5.1

52.4 5.6 7.4 3.8 3.9

31.5 4.3

dependence

Social Security (INSALUD) Sanidad National Central State Administration Regional Governments Local Authorities Catholic Church Red Cross Foundations

0.1

4.4 113 0.2

:::

0.5 1.2

0”::

Insurance Plans Private Institutions

12.8 8.2

Z%

14.0 7.0

Total

1046

1046 (looo/o)

515 (loo910) Sources: Centro de Investigaciones Sociolbgicas. Los Mddicos ante 10s Problemas de la Organizaci6n de la Sanidad. Research 1358 (1983).

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For more than three quarters of the profession their main practice (the one that sustains them) takes the shape of employment in public organizations. As a main job, the solo practice and the employment in private organizations represents less than a quarter of the total professional activity. Nevertheless, their second job has a high percentage in liberal-traditional and private practice (50%); standing out the solo practice (36%) and the work in private offices (50%). The liberal-private professional practice (in private health care organizations or on its own) has a clear complementary position with respect to the exercise in public health care organizations. We would differentiate two main types of organization in the Spanish hospital structure. On one hand we have the large hospital organizations, depending directly on the State, in which the health care objectives are above the medical profession’s interests. In these large organizations (65% of the INSALUD hospitals have more than 200 beds, and 75% of the Ministry of Education hospitals more than 500) the medical profession, with a clear employee status, is a minority compared with nurses and clinical assistants (Table 5). The dynamics and rationality of these large organizations more and more leave the medical profession out of the influential and decision-making positions, which produces conflicts between the interests and perspectives of the organization and those of the medical profession. Table 5 Health care personnel

Personnel

Managerial (%) Doctors Residents Nurses Clinical assistants Clerical workers Manual workers

according

Total

0.8 15.0 2:*: 16:0 7.0 22.0

to hospital ownership

INSALUD

0.3 15.2 3.1 31.3 24.5 7.5 21.0

Ministry Local Administration of Education 0.2 21.3 6.5 26.7 25.0 8.5 17.5

0.8 15.0 2.8 18.0 33.0 6.0 26.0

Catholic Church 1.8 23.5 1:.: 28:0 6.0 24.0

Red Cross 1.1 27.0 2.0 18.0 24.0 6.5 22.0

Private

1.9 29.0 0.8 17.5 24.0 6.0 21.0

Total (%)

100

100

100

100

100

100

100

Average size (in beds)

197

468

837

288

217

110

81

Sources: INE, Estadisfica de esfublecimienfos saniturios 1982 (Madrid: INE. 1986).

The political cooption of the Spanish medical profession has as a central axis the formation of a professional organization politically dependent on the State with a centralized, presidential and authoritarian structure. The By-laws of both the Organizacibn Me’dica Colegial and Consejo General de Colegios Ofbales de Mt?dicos- Medical Association Councils - (1945,1946 and 1967) develop a model of authoritarian organization that secures the political control of the profession on behalf of medical oligarchies sharing the francoists’ projects and ideology [31]. The Consejo General de Colegios Ojiciales de Mkdicos and the OMC (as the top [531

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of the centralized power of the profession) are endowed with a delegated authority of the State (in a corporative relationship) to design the shape and the future of the profession, within the limits dictated by the governmental project for the articulation and design of the SOE and the Social Security. The democratic changes in the country do not bring about great changes in the performance of the medical organization. The attempts at democratization of some of the provincial associations systematically fail before the more conservative projects of those groups that have historically controlled the colegios: the most conservative sectors. The presidential elections held over these last few years in several provincial colegios are a clear indication of the great power the professional oligarchies still have. The rigidity of the organizational structures obstructs the creation of representation channels which leads to a progressive political devaluation of these organizations, showing their lack of representativeness, and to the creation of new organizations to represent alternative professional interests. The authoritarism of the colegios is the way some professionals (already starting to be a minority) try to impose their health care and professional projects. Nevertheless, their authority (and consequently their representative legitimacy) is threatened every time by the more numerous dissident voices in the profession and their different professional, ideological and health care ideas. For more than four decades the political relationship between the profession and the State has been characterized by a consultative role of the Consejo General - Medical Association Council -. The politics of the profession are limited to the collaboration with Social Security, as a way to secure a professional and economic shelter for as many professionals as possible. They try to maintain both the professional monopoly and the delegated control over the public health system. Their political dependency offers them as a compensation a considerable amount of political maneuvering. Their collaboration in the outline of the Social Security health care system allows the Spanish medical profession to define a professional project (of assault of the medical market) different from those of countries with predominantly private health care markets. It is a policy for survival and development within health care organizations paid with public funds. The medical profession, after some years of forced adaptation, reacts by planning the take-over of both the organization and the design of the public health care sector. The power of the medical profession during the sixties and seventies was very large. The State leaves an expansive health care system in their hands with little control over the money and over its organization. The professional project it develops aims at the total control over the public health care system and the monopoly of the medical market. Its manpower policy follows the same expansive line; the growth in the demand of health services (caused by the expansion of the system) makes the expansion of professional resources also necessary. Those are the years of easy benefits for a profession which moves from being defeated in its liberal projects to achieve a clear accommodation success; it obtains the control and outlining of the public health care system. The outcome of this situation is the construction of a health care system that secures the professional monopoly, sustains the totality of the profession, allows them to organize their own work [541

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(combining public with private practice), increases health care demand with the extension of Social Security health care coverage (which increases the demand of their services and their power in the system), and supports a great part of the private sector that lives off the deficiencies (and funds) of the public system. The State develops a large health care market (which, otherwise, would not have reached such dimensions if it had been left to private initiative) that secures the footing of the profession: that is to say, their survival, development, and maintenance of their traditional monopolies. It is a period of expansion politics, of conquering, in which the medical profession develops to levels not reached in countries with similar culture and economic surroundings. The crisis of the healing-restorative model (its failure to face new chronic diseases with social etiologies), the economic crisis of the State and the increase in health care expenses, and the political power given to reform projects threaten the balance of the medical power within the health care system. The curative medicine paradigm is partially replaced by the preventive paradigm (much cheaper and with a larger protagonism of other health care professions) which threatens its traditional monopoly over anything that has to do with Medicine. The need for control of the economic resources opens the door of health care organizations to the rationalizer paradigm which takes the doctor’s place in the managing and organization of the system. The professional monopoly over the organization of its own work quickly disappears. The power of the medical profession in the health care system has been reduced, and that forces a clear political defense. That is the situation that defines the government of Dr. Ramiro Rivera as the president of the CGCOM - Medical Association Council - between 1982 and 1986, coinciding with the first socialist government, The first socialist government differs from the second in that there is a higher degree of ideological projection (compared with the higher pragmatism and economicism during the second government). The socialist health reform tries to build a health care system to satisfy the needs of the population, and at the same time to drastically reduce the medical power (which they consider responsible for most of the health care problems). It is a reform project that has as a main objective the substitution of the corporative-traditional medical power for a more ‘health-care oriented’ power. The political battle between the CGCOM/OMC and the socialist government during the first socialist term (1982-86) is possibly one of the most interesting political phenomena of the new Spanish democracy. A battle in which both parts use a wide range of political artillery: insults, disqualifications, lobbying, public campaigns, sanctions, demonstrations, strikes, and so on. The hounding and cornering of the profession is counterbalanced with the practical support of the governmental reform. The profession suffers a devaluation of political and social prestige, and the government suffers an important political erosion (reflected in the electoral punishment in 1987 local elections). Ernest Lluch’s health care reform project is set aside; Ramiro Rivera’s intransigence and belligerency is abandoned. The battle had as the clearest result the deterioration of the profession’s conditions, the sharpening in the crisis of the

130

system (turned into a battle field), and the political devaluation of both parts. Since 1986 the CGCOM policy (the same way as MSC’s policy) substantially changes. From that year on they started building a new accommodation policy: being the negotiation of a new political vehicle. CGCOM’s new policy collides with high professional tension, which still causes great conflicts in the spring of 1987. Nevertheless, this new conflict has a different nature: it seems intended to accumulate bargaining power. It is not a question of defeating the adversary (or its political health care project), but rather of accumulating power and legitimacy in order to enter into the political process to define the new basis of the health care structure. This new policy seems to be gtving its first results: the socialist government abandons the idea of a public domain SNS - National Health Service and begins to accept the idea of a mixed system. The political project of professional survival strengthens again. The medical profession accepts the new health care parameters (better to say it accommodates to them) and the socialist government adapts to the needs of survival of the medical profession. The Ley General de Sanidud (LGS) - National Health Care Act - (approved in 1986) - is the basic tool articulated by the PSOE to replace the previous LQY de Buses a2 la Seguridud Social (1963) and its health model by a model more in accordance with their definition of the Welfare State. The definition of the health care model starts in 1983 with the first drafts of the law and has its conceptual finalization in 1986 with Parliamentary approval. With the approval of the law, the conflict moves from the general political outlines to the way to develop them (which are the real elements of configuration of the health system). The new model defines health and medical care as a right, and so directs the expansion of Social Security assistance to the totality of the population. The law defines a kind of ‘National Health Insurance’ whose health services are provided by a National Health System that integrates (around the central structure of INSALUD) all public health care services. Health care is turned into a public service and the State keeps the monopoly over its provision. Due to endless debates and confrontations, the resultant health care model is relatively ambiguous, but it seems to sentence the medical profession to a central working market: the public one. The profession does not oppose the spreading of Social Security health care, but objects to the State having the dominant role over the control of health-medical services [37]. For an important part of the profession, the control of the State means the lessening of their power in organizing their work and over the demand of their professional services (the lack of freedom to choose one’s physician takes away from the individual practitioner all control over the demand of his/her services). It is precisely this part of the debate which makes the relationships with the private sector, in the frame of the SNS, not very clearly defined, leaving the possibility of shaping those relations during the implementation process. The characteristics of professional practice are an important part of the debate over the health care model at the end of the eighties. The LGS limits professional activity in a market of medical organizations of public supremacy. With that the employee status of professionals in organized structures is strengthened. The reform 1561

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projects, developing the LGS, for primary health care and for the hospital system have as a primary objective to rationalize the performance of such organizations. It is, then, a question of putting an end to the ‘anarchic organization’ (with multiple rationalities, power structures and contractual relationships) and organize professional work according to production criteria (not only medical criteria). As elements to single out, there are the attempts to hierarchize (1984) and systematize (an eight-hour working day) professional activity (1985). The strong opposition of the profession to adapt to an employee status is translated into actions that obstruct the legal and practical implementation of those changes. The two political measures end up by being overruled by the Supreme Court (1987), but given the importance of those criteria for the socialist reform it does not seem that such obstacles will stop the process of standardization of professional work in health care organizations. The government pretends to endow public health care organizations with managers carrying out organizational objectives rather than medical objectives. With the Reglamento de Organizacibn y Funcionamiento de 10s Hospitales de1 INSALUD (1987) the bureaucratic authority of the organization gains power over the medical authority. The figure of the ‘manager’, an expert in health administration and not in Medicine, takes the physician’s place in managing the health care institutions. The managers are the ones who end up setting the outlines for the organization of professional work and who distribute the vital resources of the organization. The profession sees its autonomy within the organization limited to its technical (clinical) autonomy which it often uses as a platform to widen its maneuvering possibilities. A great part of the tension in the hospitals during the 1987 spring as well as the obstructive attitude of some professional sectors are part of the struggle over the criteria to dominate in the health care organization. The loss of professional power means another step towards their proletarianization: as much because they lose control over their work as because their technical-clinical autonomy resents the economic constraints imposed by the managerial rational. Another of the basic aspects in the debate between the State and the profession is the one related to the medical professional status. The LGS configurated his/her position as employee in public organizations. The application of bureaucratic criteria, designed for the administration of the State, to the medical services with the application of the Ley de Incompatibilidades (1985) means for the practitioner the impossibility to maintain full-time employment in both the public and the private sector (or to hold more than one job in the public system). What, on the one hand, means the rationalization of work (a tendency for full time jobs in exclusive dedication), means for the professionals a loss of freedom in organizing their own work. The application of the Ley de Incompatibilidades - Incompatibilities Bill - is framed in one of the worst confrontations between the State and the profession. The latter reacts energically in front of the lessening of the privileges acquired in the past (flexible schedules, jobs in several institutions, compatibility of public and private jobs) but, above all, in front of the future impossibility of articulating, according to their own criteria, their professional activity (limited by the State regulations derived from their status as public employees). The strikes and civil disobedience 1571

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actions carried on by a large part of the profession provoke, as an immediate response from the government, administrative sanctions which are replaced later with more flexible positions, once the most flagrant cases are solved. The result of this political battle is still uncertain: the State conceptually imposes its rationality although it must also accept the special characteristics of the health care system and adopt less strict bureaucratic criteria. An important power test among the different alternatives takes place during the last labor union elections in the public administration (at the end of 1987). The State administration imposes this kind of elections in the health care sector in spite of the professionals’ opposition. In these elections there was a confrontation between the public employees’ criteria (held by the Socialist Administration and certain professional sectors such as the Coordinudoru de Mkdicos Hospituhrios), union criteria defended by traditional labor unions (UGT and CCOO) and professional criteria defended by the leading professional union (CESM) and the Colegios Ojiciafes. The socialist administration accepts the employee’s and union alternatives because they both allow the development of its model of health care organization; but it openly opposes the professional alternative which, nevertheless, wins the elections. Although the positions are less radical than in other debates, the topic of professional supply assumes a progressive importance when the other debates gradually relax. There are two main issues: the excess of professionals and the type of professionals needed in the future. The excess of professionals raises problems and tensions in the professional collective as well as for the Administration. It is the result of the expansive policy of the past as well as of the failure to elaborate restrictive human resource policies when the health care market starts sensing the first signs of recession. The restrictions (nwnerur clausus) to the admittance in Medical Schools are not enough to solve the problem. The profession has not taken radical measures (even though the excess of professionals diminishes their bargaining power in the market), neither has the State been able to define, until very recently (1986), the manpower needs of its health care structure. The union interests, which are becoming more and more important due to the progressive dependence on a salary of many professionals and that cannot be included in the politics of the Colegios de Mkdicos given their more corporativist nature, are represented by the Confederucibn Espuiiolu de Sindicutos Mkdicos (CESM), the Federucibn Espuiiolu de Sindicutos Mbdicos (FESIME), CC00 and UGT, among other organizations. The type of professional practice is a clear differentiating element. The diverse practicing interest are articulated and represented by the Coordinudoru de Midicos de Hospitules, the Feukrucibn de Mkdicos de Hospitules de1 INSALUD, Federucibn de Mkdicos Tin&ares(rural), Federucibn de Mkdicos de Asistenciu Primuriu, and the Federucibn de Mbdicos de Clinicus Privudus. The political

and ideological differentiation, with clear effects over the models of professional practice, is represented by the OMC, the CESM, the Federucibn de Asociuciones puru la Defensu de la Sulud Publica, and the Mesa por un Servicio Nucionul de S&d. This diversity of conceptions, in some cases very confrontational, have some weakening effects in the representation and defense of those interests. To all that, WI

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we should add the difficulties imposed by the State which does not allow channels for the representation and formulation of sectorial interests, and the lack of political and social legitimacy of this way of interest representation. The representation of professional interest is also characterized by its fragmentation and by the struggle between the different sectors and organizations in order to obtain some kind of representative legitimacy. Over the past years, the struggle for legitimacy characterizes the political life of the medical profession. We can distinguish two politically differentiated periods; the first socialist govermnent (1982-1986) and the second socialist government (1986-1990) during which the political leaders of the main interest organizations (Ministro de Sanidud y Consume, the president of the OMC, and the Secretary General of the CESM) as well as their political strategies change. During the first period there is a high level of political conflict between the Central Administration and the professional organizations (those are the years of the political outline of the new health care system). The Organizacibn Me’dico Colegial strengthens itself politically with Ramiro Rivera who imposes his criteria over most of the Colegios Profesionules and presents a homogeneous official block. The professional unionism consolidates, with the implied support of the OMC, in a dominant professional union (CESM) which takes FESIME’s place (with more conservative interests) and neutralizes the attempts of more traditional labor unions CC00 (communist) and UGT (socialist) to introduce themselves into the medical profession. The CESM, which during this first period produces serious labour confrontations with the State, gets as a professional union the support of a large part of the profession (specially non-hospital sectors). The FADSP, as an ideologically leftist professional alternative holds opposite positions with the OMC and the CESM (with conservative political positions) and close to parties on the left (PSOE in power) and PCE (communist). The second period shows some political parameters which are different from the first. The apparent balance of representation configurated in the previous four year period changes when there is a sprouting of new conflicts of representation. The change of the leaders of the OMC brings the softening of conflicting positions and the adoption of more negotiating attitudes with the MSC. That is also the direction taken by the new leaders of the dominant union organization CESM. Nevertheless, the medical arena, far from peace, boils with new conflicts generated by the worsening of the crisis of the health care system. Some Colegios Provinciufes (specially in Madrid) question the negotiating positions of the new political leaders of the profession and, from more conservative positions, plead for a new outbreak of the conflict. The OMC representation power, once it abandons its radical political role, is threatened from within the very same organization.

Conclusions The benefits of its political dependency/co-option start to diminish in the early seventies, first with the economic crisis, and later with the restoration of a democratic political system. What had been a growing demand of professionals is dras1591

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tically restrained by the State’s financial problems and the restraint of the Social Security expansion. In the meantime, without anything drastic being done about it, the supply of physicians keeps growing and the first problems of excess of professionals appear. The bargaining power of the medical profession in the health care market is reduced when moving from a position of high demand of its services to one of a low demand. Since 1979 the health care reforms have tried progressively to reduce some of the privileges the medical profession inherited from the Franc0 period: its power in the organization and management of health care organizations and its wide monopoly over anything concerning health. Since the beginning of the seventies, the ability of the non-democratic and authoritarian structures of the medical organizations (Colegios Oficiales de Mdicos) to represent the interest of the profession has been questioned. The loss of political representative legitimacy of the Cofegios Ojiciales de Mtfdicos is added to the progressive loss of the power/authority delegated by the State. The Francoist inheritance for the medical profession means precisely its political weakness and its practically total dependency on the State. The first democratic decade is characterized by the attempts of the profession to politically strengthen itself and to obtain independence from the State. The high level of authoritarianism of the official organizations (mainly controlled by the professional right) favours the appearance of alternative professional organizations (syndicalist, political, ideological) which rival with the official organizations for the representation of the profession. The political division of the profession negatively affects its political and bargaining power which added to a high level of authoritarianism and a lack of negotiating abilities of the State gives way to confrontations and disproportionate political reactions. The Spanish medical profession is first politically dominated to successfully implement the franquist project, and in the democratic period great efforts are developed to maintain its weakness in order to prevent its frontal opposition to the socialists health care reforms. The profession moves from a limited and autarchic market (until 1963) to a great expansive market (1963-1975) and later to a market which is stabilized and remodelled (19761987). During the years of development of the public health care system, they turn to the medical profession to secure its proper running. Those are the years during which many professionals have - and often are forced to combine - two or three jobs as an average (in the public sector in 1974 the average number of jobs per professional is 1.3). Once the demand for professionals stabilizes and the rationalization of the system becomes the main priority, the large supply of physicians becomes a problem, and unemployment and the issue of incompatibilities (holding several jobs in the public sector) enter into the political scene. The dynamics of growth generated by the earlier demand of professionals and good expectations responds in a slow way to the restrictive messages from the health care system itself. The increase in number of students and professionals is smaller every year; but, in spite of that, it is still too high for the present needs of the Spanish health care system. The results in the process of accommodation (or adaptation) of the medical profession to the creation of a dominant public health care market takes shape WI

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in their main dedication to the public sector (whose expansion favoured the development of the profession) and a complementary private-liberal exercise which satisfies a demand that is not absorbed by the public sector. In their main job, the professionals practice medicine in organized structures (from the most ‘anarchic’, such as the outpatient services, to the highly hierarchic hospitals) in which they lose control over the organization of their work and even over the form of the final product offered. Liberal practice turns into a residue of professional activity in tbe presence of the power of organized medicine (public or private). Although the development of the Spanish medical profession has implied that an increasingly larger part of the profession centers its practice in the frame of hospital organization, its participation in the complex structure of these organizations has diminished as time goes by. Hospital organization evolves according to its own dynamics and little by little stops being the profession’s exclusive domain. The organization develops its own needs and turns into an institution in which the medical profession, although it still has some of its power and autonomy, is clearly a minority. There are three main kinds of professional practice in the organizational setting: (1) in the large public hospitals, where their activity is a part of a bureaucratic organization; (2) in the private hospitals, in which the professionals still hold an important role in the organization of their own work and the organization of the structure of the institution; and (3) in the primary health care area where ‘organizational anarchies’ (in the terminology of ‘anarchic organizations’ used by J. March and J. Olsen, 1976) still gives them a wide area for maneuvering and of professional independence. The dominant role of the ‘rationalizing’ paradigm in the field of public health is creating a strong dynamic to supplant the medical professional authority with the organizational authority both in hospitals (for reasons of productivity and expenses) and in primary health care (for efficiency reasons). While in hospitals the final victory of the paradigm seems imminent, in the field of primary health care a higher level of professional resistance restrains (politically and organizationally) the attempts at organizing some areas of professional practice which historically were always individual. The professional project monopolizes the outlines of the health care system which is characterized by the dominant role of curative medicine (which is the legal and exclusive medical profession’s monopoly) in front of other possible projects. The supremacy of the curative paradigm is a key element in analyzing the power of the profession. It secures the continuity of the professional offer as well as the demand for its specific product (restorative medicine). All of it within the frame of a professional work organization which, in spite of public ownership, is nevertheless very similar to the image of liberal practice. The social organization of professional practice in the public health care system is controlled by professional criteria: a high degree of freedom in practice (partial jobs in several institutions), and a status that is more similar to that of consultant than to that of employee (specially in outpatient and primary health care services). In this sector the role of the State seems to be limited to providing the money and equipment necessary for professional practice. The ‘anarchic’ organization of these institutions allows 1611

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the professionals to have total control over the organization of their practice. The dominant role of the ideology of economic rationalization represents a hard blow for the profession when the doors to the public system are closed for the new professionals. In a way, the conditions of life in the public system, to which the profession had adapted easily, are increasingly knocked down. Their very peculiar professional and market project is practically destroyed. This situation brings: (1) a crisis in the legitimacy/representativeness of the professional organization; (2) a political reaction to endow these organizations with a new political power; and (3) the elaboration of an alternative professional project confronted with the government project. The Medical Association starts to articulate a political role which it had lacked during the Franc0 years. Something similar takes place with the training of the specialists needed by the system. The change in the health care model has not been accompanied by substantial changes in their training: they still maintain the specialization model for a large hospital market when the socialist health care model needs other kinds of medical specialists: in primary health care, preventive medicine and public health. In the debate over the characteristics of the health care model and the professional activity, the issue of professional supply takes a secondary place. As a consequence, the socialist reform is not backed up by the number and kind of professionals it needs, and the project of professional survival is aRcted by the increasing number of jobless physicians. The interests of parts and of the totality of the profession are articulated through a variety of organizations, some with a high degree of representation and others with more marginal levels. The diversity in professional practice, and even political orientation, splits their interests. The ideal type of professional practice that those physicians socialized in a public health care market and working in large hospital organizations have is quite different from the conception that family doctors (or the solo-practitioners) have. The incapacity (and the crisis of legitimacy) of the Organizacibn Mkdica Colegial to assume the diversity of opinions favoured the appearance of diverse organizations of medical interests. The organization of professional interests presents a changing image as a result of the movements within the profession to build its own mechanisms of representation. The traditional organizations - the official ones - lose power and professional legitimacy in the presence of the strength of the professional union (CESM) and the Coordinadora de Mt?dicosHospitalarios (CMH). The balance of forces in the profession finds a legitimating resistance from the State. In fact, the birth and strengthening of CMH (with radical positions of professional defense) collides in 1987 with the official denial to accept their representation. This situation worsens the hospital conflict and produces three months of hospital strikes in the spring of 1987. Part of that conflict has its cause in the struggle of part of the profession to create its own representation mechanisms (CMH) and to obtain political acceptance in its negotiations with the Central Administration of the State. During the last two decades, the Spanish medical profession has been the protagonist of an unprecedented social and political transformation. The changes in the organization of health care have given place to modifications in structures, WI

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characteristics and professional projects. The political changes in the country have made it possible for those transformations to be reflected in a new political dimension of the profession. Nowadays, the medical profession plays an important role in the Spanish social policy. By the end of the eighties the medical profession has clearly reached the status and organization of a modern corporation. In the meantime, power conflicts and struggles reflect the changes in the structures of interests and of protagonists generated by the new project of professional survival. All this is in the reference frame of transformation of the Welfare State and the crisis of legitimacy of the public health care model.

Appendix A LAWS AND REFORMS

Postwar Period (1939- 1966)

1942: Compulsory Health Insurance Act (Ley de1 Seguro Obligatorio de Enfermedad - SOE)

1944: National Health Act (Ley de Bases de Sanidad National). 1945: By-laws of the Official Medical Association 1946: Establishment of the Medical Association Council (Consejo General a2 Colegios Oficiales de Mt!dico.s).

1955: Medical Specialties Bill. 1955: National Advisory Committee on Medical Specialties. 1958: Regulations of Medical Specialties. 1962: Hospitals Bill. 1962: The Ministry of National Education controls the awarding of diplomas to medical specialists. 1963: Social Security Act (Ley de Bases de la Seguridad Social). 1966: Legal Statute for the Social Security doctors.

Development Period (1967-1975)

1967: By-laws of the Official Medical Association. 1971: The Ministry of Work regulates the activities of resident MDs within Social Security health care institutions. 1972: Functioning norms for the Social Security health care institutions. 1974: Professional Associations Bill.

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Democratization Period (1976-1981)

1977: Libru Blunco de la SeguridudSociaf. (Official Report on the Social Security). 1977: Estudistica deprofesionules sanitarios: A&x 1974-1975 (Health Professionals Statistics) 1977: Creation of the Ministry of Health and Social Security. 1977: The Ministry of Health and Social Security regulates postgraduate training of MDS. 1978: The Instituto National de Previsidn (INP) becomes the InstituteNucional de la Salud (INSALUD).

1978: General Education Law. 1978: New regulations for the awarding of medical specialties diplomas. 1979: Task Force for the Health Care Reform. 1979: Creation of the National Public Health School. 1979: The first selection measures (Nwnerur claurus) to enter Medical Schools are applied to reduce the number of first-year students to a maximum of 7320 for the whole county. 1980: New By-laws for the Official Medical Association. 1980: A Health Care Reform Bill is sent to Congress. 1981: Creation of the Ministry of Work, Health Care and Social Security. 1981: Creation of the Ministry of Health Care and Consumption (Ministeriu de Sanidad y Consumo - h&SC).

First Socialist Government (1982-1986)

1982: Health Care Coordination Bill. 1984: New regulations of medical specialization. 1984: Norms creating a hierarchical structure in the Social Security outpatient institutions. 1984: First Ministerio de Sanidad y Consumo fellowship program to study abroad. 1985: Incompatibilities Bill. 1985: Introduction of full time working schedules in the Social Security health care institutions. 1985: Proposal of a new Professional Associations Law. 1986: National Health Care Act (Ley General de Sanidad - LGS). 1986: Dentists Bill. 1986: First official report on physician manpower: Oferta y demanda de m.kdicos en Espaiia

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Health Care Reform (7987-1990)

1987: Creation of the National Health Care System (Sisrema National de SUM SNS).

1987: Bill regulating the organization and functioning of the INSALUD hospitals. 1987: Conflicts in the selection process of resident doctors (MIR). 1987: The revolt of physicians: hospital crisis and conflicts. 1987: New wages system for the INSALUD health care personnel. 1987: Debate on the Estutlcto Marco (bill regulating the professional status of the INSALUD health care personnel). 1987: Draft of a new bill of Medical Specialties. 1987: ‘Documento de Teruel’: Self-critique and new health care program of the Socialist Party (PSOE). 1987: Labor union elections for the INSALUD health care personnel. 1987: The Supreme Court overrules the Ministerio de Sanidad y Consumo Order (April 25, 1984) setting norms for creating a hierarchical structure in the outpatient services of the Social Security. 1987: The Supreme Court overrules the Ministerio de Sanidad y Consumo Order introducing full-time working schedules in the Social Security health care institutions.

Appendix B INTEREST GROUPS

Professiona/ Interests: Official Organizations - Provincial Official Medical Associations (50).

- Medical Associations Central Council (Consejo General de Colegios Oficiales Medicos). - Dentists Associations Central Council. - Boards of Directors of Medical Schools. - Real Academia de Medicina. - Colegio de Huerfanos (Orphans Fund). Associations and labor unions representing partial interests - Federacidn de Asociaciones Sindicales de Medicos Hospitalarios.

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Coordinadora de Medicos de Hospitales. Federaci6n Estatal de Sindicatos y Asociaciones de Medicos Titulares (FESAMT). Coordinadora de Medicos Interinos. Asociaci6n de Medicos de Familia. Asociaci6n de Medicos en Paro. WI

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Professional Labor Unions - Confederacih Estatal de Sindicatos Mhlicos (CESM).

- Federacih Estatal de Sindicatos Mklicos (FESIME). - Federaci6n de Sanidad de la UGT (socialist). - Federacih de Trabajadores de Salud de CC00 (communist). Organizations of interest articulation - Sociedad Esptiola de Salud Bblica y Admnistraci6n Sanitaria.

- Federaci6n de Asociaciones para la Defensa de la Sanidad Pliblica (FADSP). - Centro de Analisis y Programas Sanitarios (CAPS). Professional Journals - Tribuna Mt!dica. - El Mdico. - Jam (Doyma). - Noticias Mtfdicas. General political interests: Political parties - Grupo Federal de1 PSOE de Salud.

- Health Care Committee of Partido Popular. - Health Care Committee of Partido Comunista de Espaiia. - Health Care Committee of Centro Democrhico y Social. The State - Ministerio de Sanidad y Consumo.

- Consejo Genaral de1 INSALUD. - Ministerio de Trabajo. - Administraci6n Institutional de la Sanidad National (AISNA). Consumers - Organizacidn de Consumidores y Usuarios de la Sanidad (OCUS). interests of the private sector: Health Care industry - Confederaci6n Esptiola de Organizaciones Empresariales (CEOE).

- Asociacidn de Empresarios de la Industria Farmachtica (Farmaindustria). - Federaci6n de Asociaciones de Clhicas Privadas. - Agrupaci6n de Clinicas y Sanatorios Privados. Insurance Companies - MUFACE.

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SANITAS. ASEPEYO. Prevencib National. ASISA. UNESPA (association of insurance companies). ADESLAS.

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