[Public health structures in Spain: a changing panorama]

In the last years the health care system in Spain has undergone very important transformations. However, the public health services have not followed a comparable process. Until 1979 public health structures were based in central services and their provincial units, on one side, and in the resources of local governments on the other. From then on began the process of transferring responsibilities and resources to the regional governments of Autonomous Communities (AC), which today manage most public health services, while the central government keeps as its responsibility the development of basic norms, the administration of public health services at borders and customs, and the general health coordination. The situation in 1995 resembles that of a Federal Country, although the Kingdom of Spain is not formally defined as such. The role of central government services is visibly reoriented towards coordination and the building of consensual and shared structures for health information, for need evaluation, and for policy formulation and evaluation. Although the General Health Law of 1986 considered public health as a main axis for all health agencies, its actual development has been more patchy. Several AC with an Autonomous Health Service have kept public health services separated from it. Besides, many public health functions and activities are developed today from other structures. The processes of change reveal two contradictory aspects. On one side, structures have been upgraded after decentralization, and teams reinforced, with trained and full-time staff. However, there is some dilution of public health responsibility in the periphery, and a lower visibility of the health authority.