[The institutionalization of public health in Spain]

This article reviews the long and complex process of institutionalizing public health in Spain, from the mid-nineteenth century to the present, highlighting its persistent structural fragility despite the accumulation of regulatory advances. Beginning with the 1855 Health Act, conceived as a response to cholera epidemics, the paper describes the gradual assumption by the State of responsibilities for protecting collective health, in parallel with the late consolidation of the Spanish state itself. It shows how, throughout the twentieth century, public health was often subordinated to a view of health policy as a matter of public order or overshadowed by the development of healthcare services linked to the Social Security system, particularly during the Franco dictatorship. The democratic transition and the 1986 General Health Act represented a decisive step forward for healthcare services but failed to fully integrate public health or provide it with sufficient resources, a fragmentation that was further exacerbated by the transfer of responsibilities to the Autonomous Communities. The 2011 General Public Health Act and, more recently, the creation of the State Public Health Agency in 2025 opens a new phase shaped by the experience of the COVID-19 pandemic. Nevertheless, the effective consolidation of public health in Spain will depend less on legislation than on the availability of sufficient and stable financial and professional resources.