The recession that started in the United States in December 2007 has had a significant impact on the Spanish economy through a large increase in the unemployment rate and a long recession which led to tough austerity measures imposed on public finances. Taking advantage of this quasi-natural experiment, we use data from the Spanish Ministry of Health from 1997 to 2014 to provide novel causal evidence on the short-term impact of health care provision on health outcomes. The fact that regional governments have discretionary powers in deciding health care budgets and that austerity measures have not been implemented uniformly across Spain helps isolate the impact of these policy changes on health indicators of the Spanish population. Using Ruhm's (2000) fixed effects model, we find that staff or hospital bed reductions account for a significant increase in mortality rates from cardiovascular disease and external causes, for 25-34 and 65-74 year-old groups, and in the late foetal mortality rate. Mortality rates, however, do not seem to be robustly affected by the 2012 changes in retirees' pharmaceutical co-payments. Contrary to expectations, we find some evidence of reduced mortality rates for cancer and female cancer as a result of the 2012 changes in migrants' access restrictions to the Spanish NHS. Overall, our analyses suggest that short-term impacts of decreases in health care provision on mortality are significant but small. However, impacts prove to be economically and quantitatively significant in the case of fatalities due to external causes, especially accidental deaths.

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This article analyzes the basic characteristics of the labor and social policies of the Franco dictatorship established in Spain after the Civil War (1936)(1937)(1938)(1939), and the links which existed between them. The offer of support to working families was presented through a paternalistic discourse of 'social justice' which was combined with tough repressive measures in the labor market. Within this context, compulsory social insurances pursued a political end, as they served to mitigate social tensions in a context of worker repression and harsh living conditions. Sickness insurance was a key element in this strategy, and it turned out to be very economical for the dictatorship, as the burden of financing the system was placed on employers and, above all, the workers themselves. This led to financial and management problems within a system providing imperfect coverage, with low benefits and serious inequalities in protection. Consequently, Spain moved away from other advanced countries which, at this time, were establishing their welfare states on the basis of two pillars: the universalization of benefits and the redistributive character of the system from a social point of view.

SummaryThe main aim of this paper is to analyse the singularity of the Spanish position with regard to coverage of the risk of sickness within the context of the different welfare models described in international literature. This analysis enables us to verify that in Spain, as in other countries, there were initially different forms of sickness coverage which coexisted, created by the market, by workers themselves and, gradually, by the state. Within this so-called mixed economy of welfare, the most extensive health coverage for the Spanish population was a result of the self-organization of workers, and this continued until the Civil War (1936–1939), not so much due to its efficacy and viability, as to the slow development of private insurance companies and the inability of the state to implement compulsory sickness insurance. The installation of the Franco dictatorship meant that the introduction of compulsory sickness insurance was further delayed, and when it was eventually passed, it offered only limited coverage, was enacted more for political than for social ends, and was to result in the virtual disappearance of friendly societies.

Using new statistical data on financing, coverage and economic and health care provisions, this article analyses how sickness insurance was introduced, managed and extended in Spain, under the Franco dictatorship, between 1939 and 1962. This article highlights how the dictatorship accelerated its implementation for political motives and this resulted in a failure of the system due to the lack of public financing and the high pharmaceutical, medical and infrastructure costs.