Health and Welfare

Health and Welfare

According to several summary measures of social welfare, Spain could best be described as being at the low end of the list of advanced industrial countries. One such measure is the Physical Quality of Life Index (PQLI) developed by the Overseas Development Council, an average of three indices--life expectancy, infant mortality, and literacy. In 1980, on a scale of from 1 to 100, Iceland, Japan, the Netherlands, and Sweden all ranked at the top with scores of 98; Spain was twenty-eighth out of 164 countries--between Puerto Rico and Bulgaria--with a score of 92. Another measure, the Index of Net Social Progress (INSP), developed by Dr. Richard Estes of the University of Pennsylvania, uses data from eleven subindices, including education, health, the status of women, and welfare. On this scale, Spain, with a score of 122 for the 1979-80 period, ranked thirty-seventh out of 107 countries, quite far behind most other West European countries and comparable to several advanced Third World states, such as Mexico and Argentina. This lower rating stemmed from Spain's poor score in the Cultural Diversity Subindex, where ethnic and linguistic fragmentation caused Spain to fall in the ratings.

Health Conditions and Mortality

On a number of indicators of health care, Spain ranked fairly high among the advanced industrial countries. In both 1965 and 1981, the country had a better population-to-physician ratio than the average of the industrial democracies (800 to 1 versus 860 to 1, respectively, in 1965 and 360 to 1 versus 530 to 1, respectively, in 1981). In 1983, with more than 115,000 physicians, Spain ranked sixth in the world in its ratio of inhabitants to physicians. Despite dramatic strides in adding nursing personnel (causing a decline in the population-to-nurse ratio of from 1,220 to 1 to 280 to 1 in less than 20 years), the country remained near the bottom of the list of advanced industrial countries on this scale. Spain also ranked below most other West European countries in per capita public expenditures on health care--only US$220 per person in 1983. In 1981 there were in Spain slightly more than 1,000 hospitals and about 194,000 beds, or about 5.4 beds per 1,000 population.

As these figures suggest, the provision of health care in Spain was highly uneven. Even with a high ratio of doctors to inhabitants, the country had still not managed to eradicate such diseases as tuberculosis (more than 9,000 cases in 1983) and typhoid (5,500 cases); and there are still even a few new cases of leprosy reported each year. The root of this problem seems to be the maldistribution of the health care resources of the state's welfare system. Hospitals in one area of the country might be seriously understaffed, while those in other regions lay virtually empty. By and large, the worst-served areas were the workers' suburbs near large cities. One press report cited the neighborhood of Vallecas, near Madrid, where a population of 700,000 had no hospital at all and had only 3 doctors in residence, who were reduced to seeing patients at the rate of 1 per minute. A principal reason for understaffing was the system of multiple hospital assignments arranged by physicians to augment their salaries. Although regulations prohibited this practice, many doctors arranged to be on duty at more than one hospital at a time, thereby reducing their effectiveness in meeting patient needs.

In terms of the causes of death, Spain fairly closely resembled other advanced industrial societies, although cancer and heart disease appeared less frequently in Spain than in more industrialized countries. Of the nearly 290,000 deaths registered in 1980, almost half (45.8 percent) were due to a variety of circulatory system problems, principally heart attacks and strokes. The single most prevalent cause of death was malignant neoplasms; about one-fifth (20.2 percent) of all deaths were caused by cancer of one sort or another. About one-tenth (9.2 percent) of all deaths were occasioned by respiratory ailments. (Spaniards were the second heaviest smokers in the European Community--EC, after Greeks. About 40 percent of adults smoked, as did 50 percent of teenagers; the average 14-year-old reportedly smoked 2,700 cigarettes a year.) About 2 percent of deaths were caused by automobile accidents, and about 0.5 percent, by suicides.

In the third quarter of 1987, there were 112 cases of acquired immune deficiency syndrome (AIDS) reported in Spain, bringing to 620 the total number of Spaniards afflicted by this disease. Although high, the Spanish figure was still less than half of that France, and it was far behind the more than 40,000 cases in the United States. Slightly more than half the AIDS victims contracted the disease through narcotics-related practices; about one-fifth, from homosexual contact; and about one-tenth were hemophiliacs.

During the 1960s and the 1970s, Spain achieved dramatic gains in reducing infant mortality. Between 1965 and 1985, the infant mortality rate dropped from being the highest among the industrial market economies, 38 per 1,000, to only 10 per 1,000 in 1985, which placed it ninth lowest in the world, on a par with other advanced industrial societies. The death rate for children less than one year old declined from slightly fewer than 13 per 1,000 in 1975 to fewer than 9 per 1,000 in 1979, and for children less than 5 years of age, it declined from 15 per 1,000 to fewer than 10 per 1,000 in the same period.

Spain also registered some improvement in food consumption during the 1960s and the 1970s, with per capita caloric supply growing by about 1 percent per year (from 2,844 in 1965 to 3,358 in 1985). In 1983 Spain ranked twenty-ninth in the world in calorie supply per capita. Spaniards daily consumed more calories than, or about the same number of calories as, the residents of Britain, France, Finland, Japan, Sweden, or Norway.

Public Safety and Environmental Problems

The reform and improvement of the country's food regulations and inspection procedures were long overdue. In 1981 Spain experienced a major public health disaster, a "toxic syndrome" still unexplained, but believed to be connected with the consumption of rapeseed oil intended for industrial use, but marketed by door-to-door salesmen as olive oil. More than 300 people died from this substance, and hundreds more were permanently disabled.

The rapeseed tragedy was only one of a number of man-made or man-aggravated disasters that Spain has experienced since it crossed the threshold into industrial society. Airplane crashes, train derailments, bus collisions, hotel fires, gas explosions--these and other tragedies were nearly commonplace in Spain. Far more people died in train accidents in Spain, for example, than in any other country in Europe. Spain suffered these disasters largely because of a combination of the advanced technology of an industrializing and urbanizing society, low standards of professional competence and private sector morality (themselves the product of rapid growth), and the state's unwillingness or inability to step in to regulate this increasingly sophisticated and complex society. Two problems of special importance can be cited here: public health and environmental contamination.

As the rapeseed tragedy illustrates, one of the chief problems in the public health field had to do with food and drink inspection and regulation. Although food containers and additives were analyzed by government chemists, the food and drink themselves were not tested before being put on sale. One report on the subject in the mid-1980s estimated that, in the whole of Spain, there were fewer than 1,000 people working full-time to check the quality of the food and drink in the 225,000 places where they were manufactured, distributed, sold, and consumed. Another check of the 3,000 restaurants, bars, and hotels in Madrid found that 35 percent of the wine, 41 percent of the spirits, and 75 percent of the milk and ice were unfit for human consumption. Rapid and uncontrolled industrialization and urbanization had left a legacy of air, water, and noise pollution that would take a major government effort many years to correct. The rivers flowing through Spain's major cities, such as Madrid or Bilbao, were little more than open sewers. One survey of Bilbao's Rio Nervion showed that 385 factories dumped their untreated effluents into it, and that the oxygen content was only 5 percent compared with the 60 percent, needed to sustain fish. In Madrid, air pollution was a major problem during the late 1970s and the early 1980s, when the suspended particle count reached an average of more than 200 micrograms per cubic meter of air, compared with the government's recommended maximum level of 80. Bilbao's atmospheric carbon dioxide level was the highest of all the cities in Western Europe. Air pollution was a problem, due to the heavy automobile traffic (in the late 1970s only seven countries in the world had more registered passenger cars than Spain), oil-fired space heating, and heavy industry.

Although there had been significant improvement in environmental protection in such large cities as Bilbao and Madrid in the late 1980s, the mid-sized industrial cities around the country were still experiencing rising populations and pollution at alarming rates. According to a 1987 study by the Organisation for Economic Co-operation and Development (OECD), Spain was one of Europe's noisiest countries, principally because there were no regulations covering industrial or automobile noise levels. In late 1987, the Ministry of Public Works and City Planning finally drafted several government decrees that, for the first time, set maximum noise levels for industrial and construction machinery, motorcycles, and automobiles, and established new regulations in building codes that would require soundproofing for residences, hospitals, schools, and cultural centers. A survey of 226 firms in Madrid showed that 60 percent of their 165,000 employees were working in noise higher than government-approved limits. In 1988 a government report revealed that Spanish industry was producing 1,700,000 tons of toxic waste material each year, of which only 240,000 tons could be disposed of by burning. When the international agency, the Oslo Convention, denied Spain the right to dump some of these wastes in the North Sea, the government had to store thousands of tons of highly toxic chemicals in warehouses along the coast of the Bay of Biscay because there was no way that they could be released into the environment safely.

Housing

Housing was another area in which Spaniards had to respond to the challenges of dramatic change. During the late 1950s and the 1960s, about 14 percent of the total population changed residence permanently from one part of the country to another, and most of these people lacked suitable housing. One of the most pressing challenges of the government and of the private sector was to find or to build housing for these millions of uprooted people. The government became involved in housing policy relatively late and then only as a source of subsidy for the private sector. The government's 1961 National Housing Plan called for the construction of 4 million new dwellings by 1976. In the hope that home ownership would help dilute the working class radicalism that had fueled the economic crises of the 1930s, most of these dwellings were to be for sale, not for rent. About half of these residences were built and were financed through the unsubsidized private sector; for most of the remainder, the government subsidized only the lending institution. Thus, government-owned housing accounted for only a very small percentage of the total number of dwellings.

The private construction sector surpassed the target of 4 million new dwellings. In every major city of Spain, slums were replaced by high-rise apartment buildings that ringed the older town centers. Despite this building boom, however, by the time the wave of urban migration had subsided in the 1970s, there were still about 1.5 million people without homes, and the figure was about 230,000 as of the 1981 census. The government's housing policy had produced millions of new homes, but, by relying entirely on the private sector to produce them, the government ensured that new construction would be directed principally toward the growing middle class because there were greater profits to be made on large, expensive dwellings than there were on small, modest ones. The government attempted to offset these market forces by placing ceilings on sale prices and on the size of units to be subsidized, but the limits they imposed were so high that they did little to enlarge the market for cheap working-class housing. Not only was housing scarce, but much of it was in poor condition. According to the 1980 housing census, of the 6.5 million buildings tallied, one-fifth (1.3 million) had been built before 1900 and another one-fifth, between 1900 and 1940. Only 37 percent could be considered to be relatively modern, having been constructed since 1961. About 70 percent of the available buildings were classified as being in good condition, but nearly 10 percent were categorized as being seriously run down and in need of repair. Some 90 percent of the buildings had running water and indoor toilets, and 94 percent had electricity; but only 20 percent had central hot water service and only 4 percent had central heating.

The Socialist government elected in 1982 estimated that the country's housing stock must be increased by between 250,000 and 310,000 units each year, if all citizens were to have their own homes by the early 1990s. Still, only about 10 percent of the new dwellings were to be government-built; 200,000 units would continue to be built, financed, and sold, annually, through the private sector. Nevertheless, by the late 1980s many believed that the housing crisis was substantially over, and that Spaniards were within a decade of achieving their goal of minimally acceptable dwellings for all. In terms of quality, however, the people had to continue to live with the legacy of the 1960's construction boom--huge, impersonal apartment complexes; shoddy construction and high maintenance costs; and high purchase costs--for the foreseeable future.

Government Health and Welfare Programs

Following the reform of the government's social services in 1978, all social security benefits were under the supervision of the Ministry of Labor and Social Security. In addition, the Ministry of Health and Consumer Affairs was responsible for public health and health education programs. In the government's 1988 budget, these programs were allocated about US$22.5 billion, a 9 percent increase over 1987 and about 23.3 percent of the total budget.

Except for unemployment benefits, most social security programs were administered under a single set of institutions created by the 1978 reform to replace the patchwork system of unions, insurance companies, mutual aid associations, and state-run programs that had evolved in haphazard fashion throughout the century. These institutions were not the only welfare system, but they did cover about 80 percent of the population, and they offered a complete range of welfare benefits, including cash payments, medical care, and social services. The programs were administered by three government agencies, together with the General Social Security Treasury, which was responsible for financial control. Cash payments were administered by the National Social Security Institute (Instituto Nacional de Seguridad Social--INSS); medical care, by the National Health Institute (Instituto Nacional de Salud--INSALUD); and social services, by the National Institute for Social Services (Instituto Nacional de Servicios Sociales--INSERSO). After the advent of the autonomous community system, several autonomous governments sought to have responsibility for social security transferred to their jurisdictions. The health care responsibilities of INSALUD were transferred to the regional government of Catalonia in 1982 and to that of Andalucia in 1983. The Pais Vasco and Valencia were scheduled to receive their authority in the health field in 1988.

As of 1984, residents had access to a fairly comprehensive program of health insurance coverage, paid for by joint contributions from workers and employers; the state added a subsidy to cover deficits. Sickness benefits ranged between 60 and 75 percent of covered earnings, and maternity benefits amounted to 75 percent of covered earnings, paid both 6 weeks before, and 8 weeks after, childbirth. Medical services of all kinds were provided to patients directly through state-run hospitals and clinics, or through institutions under contract to the state. Pension insurance or retirement coverage was available to all employees in industry, including the service industry, and to their dependents. Benefits were financed by workers, employers, and the state under the same general scheme as that used for health insurance. There were separate systems in effect for sectors that were difficult to cover in this way, including farm workers, domestic servants, seamen, public employees, miners, and so forth. Old-age pensions were payable in most cases at age 65, and they constituted 50 percent of covered earnings (the average of the highest-paid 2 of the last 7 years) plus 2 percent per year of contributions made from eleven to thirty-five years, up to a maximum of 100 percent. Pensions--usually reduced to a certain percentage of the original pension, but equalling 100 percent under certain conditions--were also payable to survivors of the covered worker.

Unemployment insurance has been available in Spain since 1919, but the state has provided benefits to those out of work only since 1961. Insured workers contributed between 1.1 and 6.3 percent of covered earnings according to 12 occupational classes, while employers contributed between 5.2 and 6.3 percent of payroll, and the state added a variable subsidy. Benefits covered the insured for up to twenty-four months under normal circumstances, and they could range between 60 and 80 percent of covered earnings. Only about 60 percent of the registered unemployed received benefits, however, because the law excluded short-term and casual employees as well as those seeking their first jobs and because agricultural workers were covered under a special program.

During the 1980s, the state's share of funding for social security programs expanded rapidly, while the proportion contributed by employers and employees declined correspondingly. In the 1970s, the state was contributing only 5 percent; however, by the 1980s the figure had risen to more than 20 percent, still quite low by West European standards. Many employers complained because of the relatively high proportion (85 percent) that they had to contribute to the non-state portion of social security funding; some even falsified records or refused to make the payments, leaving their employees without benefits. Slightly less than two-thirds of social security expenditures were paid out in cash benefits, principally in the form of pensions to the aged, widows, orphans, and the disabled. The remaining third was spent on health, on social services, and, in small part, on administration.

As in many other advanced industrial countries, Spain's welfare system was under increasing financial pressure throughout the 1980s. This was due in part to the country's economic distress, which created the dual pressures of declining contributions and tax receipts on the one hand, and increased claims for unemployment assistance on the other. Another important reason was the decline of the extended family, which in earlier times had absorbed part of the cost of helping unemployed or distressed family members. However, the main reason was that, like those in other Western countries, Spain's population was aging rapidly and therefore the state had to pay more and more in old-age pensions. These pensions tended to be quite generous, the highest, in fact, after Sweden's, in Western Europe. Between 1972 and 1982, the number of pensioners rose by an average of 184,000 each year. By 1983, when there were 4.7 million pensioners, for every beneficiary of the pension program there were only 2.3 contributors, compared with an average of five in the rest of Western Europe. Thus, in the 1980s, officials began to talk seriously about the possibility of the bankruptcy of the old-age pension system. The private sector needed to become more heavily involved through private pension plans, but in the late 1980s, legislation that would make these plans possible had failed to win government approval. In a country where the elderly have traditionally been held in high esteem and have generally been well treated, the dramatic aging of the population was still a relatively new experience that would greatly affect public policies as well as the country's social values. In 1982 there were only 62 homes for the elderly, and these cared for some 12,500 persons; by 1986 the number of centers had increased by approximately 16 percent, to 72, and the number of elderly residents had increased by 25 percent, to about 15,700. Also in 1982, some 385 day-care centers provided services to about 1.1 million elderly; by 1986, just four years later, the number of these centers had increased by 13 percent to 435, and the number of elderly served by them had increase by 55 percent, to about 1.7 million. In this same four-year period, government expenditures on social services for the elderly rose by 87 percent, direct payments to the elderly rose by more than 170 percent, and investments in facilities for the aged increased by 160 percent. It was clear that these figures would continue to increase well into the twenty-first century, raising the highly controversial political question of who would bear this fiscal burden.

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