From Refoundation to Decline: A Century of Catholic Church Hospitals in Spain (1880s–1980s)

This paper analyses the contribution of the Catholic Church to Spanish hospitals for more than a century, from the last three decades of the nineteenth century to the 1980s, when the health system model changed and when the transfer of healthcare to Spain’s Autonomous Communities was initiated. The refoundation of Catholic Church hospitals can be observed in the last thirty years of the nineteenth century, as the result of the confiscation of Church property that took place during this century. The new hospitals incorporated contemporary scientific innovations and medical specialisation. Over time, the Catholic Church ran a substantial number of hospitals (surgical, maternity, children’s, psychiatric, shelters, etc.). This work of healthcare provision still continued into the early 1940s, when the Church hospitals were integrated into the national hospital system. Catholic Church hospitals accounted for 15 to 17 per cent of the total number of beds in the Spanish health system. The most common were surgical hospitals – each with around 100 beds – located in urban areas. The contribution of Catholic Church hospitals to psychiatric care was notable (30 per cent of all beds for this purpose in Spain). This study also analyses the ten-percentage point reduction in the number of beds and hospitals dependent on the Church that occurred in the 1980s.


Introduction
After an age-old tradition, the hospitals dependent on the Roman Catholic Church (hereinafter, Catholic Church) disappeared in Spain during the nineteenth century due to a combination of political and economic factors.From the end of the eighteenth century, the Church hospitals were subject to successive confiscations.As a consequence, there was a decrease in the number of hospitals, especially in rural areas, and parts of the population formerly treated in these institutions was left unattended.1This constitutes the starting point for this research, which examines also whether the hospital system continues to have links with the Church nowadays.And if so, how have Catholic Church hospitals evolved in Spain during the twentieth century?What functions have the hospitals with links to the Catholic Church developed in the contemporary period?And what support have Catholic Church hospitals received in a progressively secular society?
The contribution of the Catholic Church to hospitals refers to numerous aspects: who owns the hospital property, the role of consecrated persons who have intervened in the running of these institutions, the participation of bishops in the endowments and management of hospitals, and the spiritual care of the sick by hospital chaplaincies, etc.
The historiography has highlighted the importance of religious personnel in the running and administrative control of hospitals during the period under review.There were various religious orders devoted to assisting the sick (the Hospitaller Brothers of Saint John of God from the sixteenth century; in Spain, the Camillians or Clerics Regular, Ministers to the Sick from the seventeenth century, the Daughters of Charity of Saint Vincent de Paul from 1790, and the Sisters of Saint Anne from the nineteenth century, etc.).2From the 1880s to the 1980s, the Daughters of Charity of Saint Vincent de Paul worked in almost all public and military hospitals in Spain, as well as in the hospitals of the Catholic Church, and were also present in 30 per cent of private hospitals.396 However, the changes and transformations referred to here are those that took place over a century (1880s-1980s) in hospitals dependent on the Catholic Church; seen from a long-term perspective, and in the knowledge that there have been very few studies on the construction and development of these hospitals, there was ample impetus for the present analysis.4 In the first instance, we examine the appearance of numerous Catholic Church hospitals that were founded in Spain in the late nineteenth century and the first half of the twentieth century; the development of these "new" hospitals and their significance up to the 1930s, when they were once again dissolved, at the end of the Second Spanish Republic.5 Subsequently, there is an account of the integration of the Catholic Church hospitals into the national hospital network in the second half of the twentieth century.The analysis considers the fact that compulsory sickness insurance was passed in 1942 (although it was not actually implemented until 1944) and that, in order to develop all the provisions envisaged, the new compulsory sickness insurance relied on the collaboration of a variety of healthcare entities, above all hospitals, from the public and private spheres, including Catholic Church-owned entities.This continued to be the case after the reform of 1963, although the number of public hospitals and beds available had increased significantly thanks to a national healthcare facilities plan [Plan Nacional de Instalaciones Sanitarias].6 The study shows that the number of Catholic Church hospitals fell in the early 1980s.There was also a change in the model of healthcare and hospital agreements, which coincided with a drastic reduction in the number of members of religious orders and congregations working in hospitals.7 Nevertheless, in 1983, the Manager (M.Campos Mayor O.H.) and the Medical Director (Dr J. Plaza Montero) of the emblematic Catholic Church hospital in Barcelona, San Juan de Dios, responded unequivocally to the question of whether the continued existence of Catholic Church hospitals still served any purpose: "Naturally" and "Of course", they replied.8These San Juan de Dios Hospital directors insisted that Catholic Church hospitals constituted "charitable social" action and were testimony to the spirit of social action related to the evangelising and apostolic goal of Church institutions.9

2
Material and Methods from a Time Perspective The Decree of 1 October 1820 abolished, among other entities, all the monasteries of the monastic orders in Spain, including those of the orders of Saint John of Jerusalem, Saint John of God [San Juan de Dios], and the Bethlehemites, and all other hospitals of any type.10Both movable and immovable property were "applied to the public credit" and declared "national assets", subject to their immediate expropriation.However, as indicated by Abós11 and Valenzuela,12 the successive decrees of the years 1834, 1835, and 1836 -along with the application of the regulations of Pascual Madoz, in the mid-nineteenth century -were above all what led to the suppression of many religious communities and the widespread reduction of the patrimony of hospitals throughout the entire country.138 Various authors, "Hospital San Juan de Dios de Barcelona.Un Símbolo," Todo Hospital, nº 5 (1983), 13.For more details of this interview, see Pilar Leon-Sanz, "Aportación de la Iglesia al contexto hospitalario barcelonès de los siglos xix y xx," in Barcelona hospitalària la ciutat i els seus hospitals, segles XIX I XX, ed. A. Zarzoso and J. M. Barcelo (forthcoming).The San Juan de Dios Hospital in Barcelona was a landmark in the reopening of hospitals run by religious orders, after the various confiscations and disentailments.9 Various authors, "Hospital San Juan de Dios," 13. 10 Germán Rueda, "El proceso de la desamortización de bienes de origen eclesiástico

98
In the case of the Saint John of God hospitals, we see a good example of what occurred.The hospitals were founded in the sixteenth century.Government decisions now led to the expulsion of Hospitaller Brothers from 52 houses.Only two hospitals, in Madrid and Seville, managed to survive, but in such adverse circumstances that the hospital care provided in accordance with the charism of the Order disappeared in the mid-nineteenth century.14 As a reaction to this process of successive confiscations or disentailments, there was, from the second half of the nineteenth century, a movement, supported by members of religious communities forced to abandon cloistered life, which inspired the appearance of new congregations and third orders, many of them dedicated to social and welfare functions.15Almost seventy new orders were created, which were joined by others that came from other countries.16In the 1870s, Catholic Church hospitals also started to be opened.The abundant sources and bibliographical studies available make it possible to investigate the causes of this phenomenon, which was mirrored by similar developments in other countries.17 To help contextualise the refoundation and development of Catholic Church hospitals, we have recourse to Pedro Carasa's studies on the Spanish hospital system in the nineteenth century;18 Rodríguez Ocaña and Valenzuela's analysis of the changes that occurred over time with regard to charitable hospitals;19 and publications by Vilar-Rodríguez and Pons.20However, we do not have clear and homogeneous records that identify all the hospitals that existed in Spain in the first three and a half decades of the twentieth century.21 A parenthesis is included in the study during the 1930s because the political events that followed the establishment of the Second Republic in Spain (1931) had a significant effect on Catholic Church hospitals.Although some continued to function initially,22 in other cases, such as the leprosarium in Fontilles, economic and administrative intervention was decreed (1931).23At the outbreak of the Spanish Civil War (1936)(1937)(1938)(1939), the government ordered "the seizure of all charitable institutions run by religious congregations regardless of who the owners are",24 and thus Catholic Church hospitals were used for other purposes.The healthcare institutions that remained in the so-called "national zone" also underwent changes: some were converted into blood hospitals or military hospitals, depending on the location and the proximity to the battlefront.25At the end of the war (1939), the different religious institutes tried to regain ownership of the establishments and locate their members who were stationed in barracks in order to reincorporate them into the staff of the hospitals.
From the point of view of methodology and sources, the study of the evolution of Catholic Church hospitals from the 1940s to the 1980s is encompassed by the creation of the so-called "National Hospital Network" comprising all hospitals, "regardless of the body that owns and runs them".26The hospitals had to be open to all the sick, "whatever their social and economic condition", but ownership was maintained, as were the characteristics and the sphere of care in which each individual hospital specialised.27Moreover, in the 1940s, compulsory sickness insurance was passed (1942/1944), which initially involved reaching agreements with public, private and Catholic Church-owned healthcare facilities in order to secure from them the provision of treatment for all the insured.Later, the Basic Law on Social Security of 1963 modified compulsory sickness insurance and limited the collaboration of certain private profit-making entities and established a series of agreements with public and private institutions and hospitals, including Church hospitals.28 The quantitative study of the evolution of Catholic Church hospitals has been undertaken using the catalogues of public and private hospitals in Spain created by the Administration, and which were periodically updated in line with the classification of hospitals established in 1962.The new classification distinguished between institutions according to the functions they performed (general and special); the geographical scope of their activities (national, regional, provincial and local); the level of care; and their ownership or patrimonial situation.The number and categorisation of different types of hospitals was also simplified.The four categories and eleven subcategories used in the first third of the twentieth century, were reduced to just two categories: general hospitals and special hospitals; then the latter were subdivided into six  .All together, they make it possible to assess both the development and the significance of Catholic Church-owned hospitals within the framework of the national hospital network.
Spanish sources have been compared and contrasted with the Annuaria Statistica Ecclesiae published by the Vatican from 1978 to 1986, and this comparison has served to contextualise the evolution of Spanish Church hospitals within the framework of the Catholic Church in general.
It should be taken into consideration that, among the causes of the changes and transformations of the Catholic Church's contribution to the Spanish hospital system, one can discern the intrinsic factors of the health sector itself (of a professional and institutional nature), and also other aspects such as social, religious, and the political and economic evolution of society.This was a period when novelties were introduced within the Church, some of them arising from the Second Vatican Council (1962)(1963)(1964)(1965).
The study ends in 1986, because in that year there was a notable change in the Spanish healthcare scenario: a new General Health Law was passed, which replaced the old compulsory sickness insurance with another system which contemplated universal health coverage financed by the general state budget.The way of concluding agreements with hospitals changed and the process of devolving responsibilities for health to the different Autonomous Communities was underway; this devolution resulted in regional governments taking over the role of regulating healthcare institutions.

Results
Two   within the framework of their integration into the Spanish hospital network and collaboration with compulsory sickness insurance.

3.1
The Resurgence of New Catholic Church Hospitals (1870s-1930s) New Catholic Church hospitals started opening in the 1870s.For example, the priest Saturnino López Novoa (1830-1905) and Teresa de Jesús Jornet e Ibars (1843-1897) founded a hospital-shelter in Valencia in 1873, which was run by the religious congregation Hermanitas de los Ancianos Desamparados.30In 1898, after the death of the founder, there were 103 shelters in Spain and America run by this order.31 In the case of the Hospitallers, the Italian Benito Menni (1841-1914), as well as being the restorer of the Order of Saint John of God in Spain, Portugal and Latin America, opened the Hospital de Niños Pobres in Muntaner Street in Barcelona in 1867, with few material resources and only 18 beds.The hospital was subsequently moved and enlarged (1882).32 In 1881, Menni founded the Sisters Hospitaller of the Sacred Heart of Jesus [Congregación de las Hermanas Hospitalarias del Sagrado Corazón de Jesús], along with two women from Granada: María Josefa Recio and María Angustias Giménez.33The new congregation's involvement was fundamental in the creation and running of new hospitals, especially psychiatric hospitals and hospital-shelters.These included the first institute for epileptics, in Carabanchel Alto (Madrid, 1899), and hospitals for the mentally ill in Ciempozuelos (Madrid, 1876) and San Baudilio de Llobregat (Barcelona, 1895),34 both of which had more than 1,000 beds, and Santa Águeda in Mondragón (Gipuzkoa, 1882),35  1).
At the beginning of the twentieth century, and promoted by the Society of Jesus, the San Francisco de Borja sanatorium colony was created (1909), dedicated to the exclusive treatment of leprosy sufferers (in Vall de Laguart, Alicante).36It was one of the three leprosaria in Spain at this time.This sanatorium, better known as the Fontilles Sanatorium, for years had more than 300 beds (336), close to the same range as the Institute of Leprosy in Trillo (Guadalajara), which was a national benchmark, owned by the General Directorate for Health [Dirección General de Sanidad], and with 465 beds.The third, the regional leprosarium in Las Palmas de Gran Canarias, belonging to the island council, the Cabildo Insular, had 66 beds (Table 2).
In the first third of the twentieth century, the largest provision of beds was in public general hospitals, which were charitable and of a provincial nature, and in municipal hospitals.37  were located in existing buildings, many of them in a poor state of repair and requiring maintenance and adjustments that entailed considerable and continuous economic contributions.This was the case, for example, with the Hospital de Nuestra Señora de la Paz in Seville, established in a building that was over 300 years old in 1880, which was constantly undergoing building work pending a possible relocation, until its total reconstruction in 2003.39

Evolution of Catholic Church Hospitals (1942-1986): a General Overview
Until the 1980s, the percentage of hospitals and beds dependent on the Catholic Church and religious institutes remained stable at around 6 per cent of all hospitals and 15-17 per cent of the total number of beds.
As can be seen in Table 3 and Figures 1 and 2, there was a progressive reduction in the number of hospitals in general from 1963.In the case of public institutions, the reduction in the number of hospitals was compensated for by an increase in the number of beds: there was a 45 per cent increase in the number of beds in this sector, from 70,834 in 1949 to 128,721 in 1986.
The fall in the number of Catholic Church hospitals continued during the 1980s (down to 60 per cent), especially among smaller hospitals (those with less than 100 beds).The total number of beds also fell, partly due to a reduction in the number of psychiatric hospitals with over 1,000 beds.40In 1986, Catholic Church hospitals accounted for 7.5 per cent of the total number of beds in the hospital system.That is, 10 percentage points less than in previous decades.

Types of Hospitals
From the 1940s to the 1980s, the Catholic Church maintained all types of hospitals (see Table 4 and Figs.3-5).
Most were surgical hospitals (46 per cent).Over time, there was a gradual decrease in this type of hospital.Between 1963 and 1986 there was a reduction in surgical hospitals of almost 50 per cent (falling from 41 to 23), and the number of beds available in this type of hospital also decreased by 21 per cent.
The proportion of hospitals allocated to the treatment of the mentally ill was high (19 per cent), and a high proportion were hospital shelters ("Nursing Homes" in Figures 3-5) (14 per cent).The Church also maintained antituberculosis, maternity, and children's hospitals: the San Rafael children's sanatorium in Segovia (240 beds), the Cottolengo del Padre Alegre in Barcelona (165 beds); and the hospital shelters of San Rafael in Barcelona (150 beds) and Madrid (250 beds), etc.However, these hospitals were not always classified among the "maternity and children's hospitals" in the official catalogue.
Seven and a half per cent of the beds in Catholic Church establishments were in general hospitals, although, over time, there was an increase in this type of hospital (which accounted for 20 per cent of the number of beds in 1986), probably due to a change of criteria in the classification of hospitals.41There was a very broad range numbers of beds in Catholic Church hospitals, from as few as 6-8 beds in some surgical hospitals to almost 1,700 in psychiatric hospitals.However, the average size of Church hospitals fluctuated very little: rising slightly from 184 beds in 1963 to 206 in 1986, and the proportion of beds according to hospital type showed a similar distribution over the years.42 The great majority of hospitals in Spain (more than 80 per cent) had a local scope.Most Catholic Church hospitals also operated largely on a local scale (65.6 per cent), although 25.8 per cent functioned on a provincial level, with a far smaller percentage of regional hospitals (8.6per cent).In 1986, there continued to be a predominance of local hospitals (46) over provincial (17) and

LEÓN-SANZ
European Journal for the History of Medicine and Health 79 (2022) 94-119 regional (3).Only one hospital, in Barcelona, was organised on the level of the "comarca", an administrative division comprising a number of municipalities (317 beds).Hospitals were mainly concentrated in the provinces of Barcelona (19) and Madrid (13).Another 27 provinces had one or two Catholic Churchowned hospitals.

3.4
The Catholic Church's Psychiatric Hospitals From the point of view of hospital infrastructure, the Catholic Church's greatest contribution to the Spanish health system was within the field of psychiatric care.This type of establishment was administered by the Orders of Saint John of God and the Sisters Hospitaller of the Sacred Heart of Jesus.
In 1963, the Church's 15 psychiatric hospitals accounted for 67.4 per cent of all Church hospital beds and 29.3 per cent of all psychiatric beds in the national hospital network.This care activity was maintained over time.
In absolute numbers, there was a 34 per cent reduction in psychiatric beds compared with 1963 during the 1980s.The 11,423 beds catalogued in 1963, or the 11,566 in 1970, fell to 7,533 in 1986 (Fig. 6).
There was an increase in the number of small psychiatric hospitals (with less than 100 beds) in the 1980s and, above all, the number of hospitals with more than 1,000 beds decreased significantly.Nevertheless, psychiatric hospitals continued to account for the largest number of Catholic Church hospital beds (55 per cent).Furthermore, they accounted for 22.7 per cent of all psychiatric beds in Spain's national hospital network in 1986,43 and remained a part of this official network during the entire period under study here.44

3.5
The Ecclesiastical Framework As can be seen in Figure 7, an analysis of the data of the Annuaria Statistica Ecclesiae shows that between 1978 and 1986 there was a widespread reduction in the numbers of Catholic Church hospitals in Europe and especially in Spain.According to the data of the Ufficio Centrale di Statistica della Chiesa, by 1986 there remained only 39 per cent of the hospitals that there had been in 1978.45 43 Olga Villasante, "Las instituciones psiquiátricas madrileñas en el período de entresiglos: asistencia pública frente a sanatorios privados," Frenia, 5(2005), 69-99 studies the psychiatric hospitals of different ownership in Madrid, especially Santa Isabel in Leganés, which benefited from the collaboration of the Hermanas de la Caridad.44 Leon-Sanz, "Hospitales de la Iglesia," 305.45 Since 1978, the Annuaria Statisticum Ecclesiae have indicated that "the number of welfare institutions owned or administered by ecclesiastics or religious institutes in the various ecclesiastical jurisdictions constitutes an index of Church activity in favour of people in need of care and assistance".The categories include "hospitals (general and specialised); dispensaries; leprosaria; homes for the old, the chronically ill, invalids and the handicapped; orphanages; nurseries; matrimonial advice centres; other charitable and welfare institutions (hostels catering for the young, etc.)".There were 6,642 such institutions in 1978.

Discussion
The following discussion focuses the continuity of care provision and, at the same time, the dynamism of Catholic Church hospitals throughout the 100-year period studied, which enabled constant adaptation to changing circumstances.The factors that were influential in the decrease of the number of Church institutions and beds in the 1980s are also commented upon.

Continuity of Care Provision and Dynamism in Hospitals with Their Own Care Programme
The hospitals owned by the Catholic Church originated with different goals and each one, in accordance with its origin and the religious order running it, maintained its own care programme over time.The creation and presence of Catholic Church hospitals in the first and a half decades of the twentieth century was in response to the need in Spain for social and healthcare assistance.Although the number of hospitals gradually increased,46 Spain's hospital infrastructure was precarious and characterised by fragmentation, heterogeneity, the small size of hospitals, and territorial inequality.47 Many of the private centres were hospitals and clinics with few beds; many had their own specialisms (in surgery or some other medical areas), having been created by specialist doctors or by associations of medical-surgical specialities.There were also private initiatives of a charitable and humanitarian nature, hospitals with a larger number of beds, such as Hospital de San Pablo in Barcelona, the Basurto hospital in Bilbao, and the Marquis of Valdecilla's Casa de Salud in Santander.There were also hospitals that specialised in the work sphere and that treated those involved in industrial accidents: the Clínica del Trabajo, dependent on the National Welfare Institute [Instituto Nacional de Previsión],48 and other institutions linked to mutuals or friendly societies.49 In the refoundation of Catholic Church hospitals in the last three decades of the nineteenth century, the Catholic Church's social doctrine, developed on the basis of the Rerum Novarum encyclical of Leo XIII (1891) is noted as having played an important part.50 The contribution of religious congregations, both male and female, to the social and hospital care that emerged at this time was also influential.51In the functioning of hospitals, the fulfilled by the religious congregations and orders changed over the years; eventually, many of the hospitals in which they worked disappeared.52 The new hospitals that appeared in the late nineteenth and early twentieth century were mainly specialised hospitals, focusing on the care of certain types of patients.The hospital-shelter of San Rafael opened in Madrid in 1892.Its director, José Álvarez Sierra, even attributes the development of specialised hospitals in Spain to the new foundations of the Saint John of God hospitals.53 The Catholic Church maintained all types of hospitals for a considerable period.The most common type was the surgical hospital, each with around 100 beds and located in urban areas, mostly in Madrid and Barcelona.It was also the most common type of hospital in the Spanish hospital network.
We have seen that the Church's greatest contribution to the hospital network corresponded to psychiatric care, both in terms of the number of hospitals and the number of beds.This was made possible because a double care network for the mentally ill that was established in Spain in 1852: one public, managed by the provincial councils, and the other private.Public psychiatric hospitals were insufficient and poorly medicalised, and those of the Catholic Church were among those subsidised.After several attempts to transform hospital psychiatric care, from 1955 onwards it enjoyed the support of the National Board of Psychiatric Assistance (panap, Law of 14 April 1955), which continued to establish agreements with public and private centres.panap's activity lasted until 1974, when it was replaced by the National Institutional Health Administration (aisna).The integration of all types of patients into the National Health System was not fully realised until the General Health Law of 1986.5451 Feliciano Montero, "Justicia y Caridad.Entre la beneficencia y la reforma social," in Cuidados y consuelos: cien años de Fontilles  The care of the mentally ill in Church hospitals was also feature of healthcare provision in other countries.One such case is Les Frères de la Charité55 dedicated especially to the care of the elderly and psychiatric patients in Belgium, the Netherlands, Ireland, and elsewhere.56This institution also had a presence in the United States.57 As well as caring for the mentally ill, the healthcare provided by the Catholic Church also continued to place a special emphasis on looking after the elderly, children, and patients with special diseases such as leprosy.The leprosaria continued to be authorised as part of the official hospital network during the period under study.58

4.2.1
Changes in the Management and Secialisation of Hospitals Between 1963 and 1986, the number of public beds doubled, growing from 99,611 to 186,051, and the size of public hospitals tended to increase: whereas the average size in 1963 was 88 beds, by 1986 it was 480 beds per hospital.
Meanwhile, there was a decrease in the number of private hospitals, and there was also a fall in the number of Catholic Church-owned hospitals.
All hospitals, including those of the Catholic Church, had to take on board changes in hospital management, which resulted in a drastic reduction in the number of both small hospitals and large psychiatric hospitals, changes that took place in the 1980s.
As highlighted by León Sanz and Sarrasqueta, there were changes in the functions of hospitals over the years, and also in the ways that they were managed, due to the introduction of new hospital codes of practice that were emerging in the 1950s, after the Second World War and in the context of the Barceló and Comelles point out that the health policies pursued in Spain throughout the twentieth century led to a model centred on the hospital and that this caused an imbalance between hospital care and primary care.The economic resources required by this "hospital centrism" were greater.Furthermore, high-quality medical professionals were mostly concentrated in hospitals, and large outpatient units were incorporated into hospitals, which functioned as a first point of care for many patients.60These characteristics can be observed in Catholic Church hospitals such as San Rafael or Hospital-Asilo Beata María Ana de Jesús in Madrid, and Sanatorio Nuestra Señora de la Esperanza in La Coruña, etc.
In the case of psychiatric hospitals, including those belonging to the Catholic Church, changes in psychiatry and the model of psychiatric hospitals were extremely influential, especially due to pharmacological innovations and new psychiatric therapies.These led to a widespread reduction in the number of psychiatric beds and the appearance of psychiatric hospitalisation units in general and acute care hospitals.61In 1986, despite the fall in the number of hospitals and beds, the contribution of the Church's psychiatric hospitals to the national network continued to be significant.
In other areas, institutions had to develop new specialities (care of chronic patients, long-stay units, etc.) in order to adapt to changes in care provision and also due to healthcare demands arising from an expanding public health system, as well as the development of new medical professions.This was the case, for example, for the Fontilles Sanatorium which, at the start of the 1990s, dedicated part of its facilities to caring for the elderly, as well as continuing to provide care for leprosy sufferers. of the economic crisis of the 1970s and increased costs arising from the incorporation of medical and technical advances.
Consequently, and especially during the 1980s, some Catholic Church hospitals experienced a change of ownership.Such was the case, for example, for the Hospital de San Pablo y Santa Tecla in Tarragona which became a part of the Xarxa Sanitària I Social Publica.Glaser informs us that, in countries with more than one religion, it was less likely that hospitals would be nationalised, whereas in countries where one religion predominated, such as in Spain or Italy, the Catholic Church was unable to resist public pressure.66 Those hospitals that survived had to improve their premises, equipment and services, in order to meet the requirements of the agreements with the health system.Catholic Church health facilities had to establish programmes that made them viable (by means of adequate financing, qualified professional staff, and good functional organisation) and which, at the same time, guaranteed legitimate institutional interests.Thus, for example, whereas there were 7 Catholic Church hospitals included in the group of the best hospitals (group A) in 1963, by 1970 there were 19; in 1963, there were 44 Catholic Church hospitals in group C (a group which met fewer requirements), a number that by 1970 had fallen to 38 (Fig. 8).67

4.2.3
Ecclesiastical Questions The reduction in the number of Catholic Church hospitals was also conditioned by the profound changes that took place during this period in an ecclesiastical context: the post-Council crisis and the decrease in religious communities from the 1970s onwards was influential,68 and it was an issue that had global repercussions.69 Furthermore, the establishment of the agreements between the Social Security and Catholic Church hospitals also evinces the complexity arising from the changing relationship between Catholic Church and State,70 especially after the change of government brought about by the of 1982.
At a time when the number of religious vocations was falling, and in a society that did not always share the same values, Catholic Church hospitals had to base their Christian identity not only on religious orders, but also on a growing number of professionals who shared the same religious or ethical doctrine.Moreover, they had to partake in this work alongside others who did not share these beliefs and values.71

Conclusions
The evolution of Catholic Church hospitals in Spain evidences the intrinsic dynamism of the hospital as an institution.Many aspects of hospital management changed the second half of the twentieth century (the number of public hospitals, the size and number of beds, the type of hospitals and the specialisations provided, etc.).72At the same time, I have shown the continuity between the hospitals re-established or founded in the late nineteenth and early twentieth century, and those which continued to function in the second half of the twentieth century.
figure 4 Evolution in the number of beds in the different types of hospitals dependent on the Catholic Church figure 5 Percentage of diverse type of Catholic Church hospitals and beds with respect to the total number in Spain (1963) source: catalogue of public and private hospitals in spain, 31 december 1963 (boe 1966).prepared by the author.
26 Law 37/1962, of 21 July, on Hospitals.Boletín Oficial del Estado boe [Official State Gazette], no.175, Art. 4. The new regulation defined the hospital as an "establishment intended to provide medical and clinical care, notwithstanding the fact that preventive and rehabilitative medicine and outpatient treatment may also be practised there if deemed convenient" (Law 37/1962, Art. 1).27 Law 37/1962, Art. 2. 28 Law 51/1980, of 8 October, boe n. 250; and previously Royal Decree-Law 36/1978, of 16 November, boe nº 276, which was completely repealed in 1980.Preamble: "The system of agreements with public and private institutions for the purposes of hospitalisation is Other sources that have been incorporated are the yearbooks of the Spanish National Statistics Institute [Instituto Nacional de Estadística] and the National Hospital Catalogues published by the Ministry of Health and Consumer Affairs over the years standardised, thereby applying the principle of coordination of healthcare envisaged in the Law on Hospitals."For further details, see Jerònia Pons and Margarita Vilar, "The genesis, growth and organisational changes of private health insurance companies in Spain (1915-2015)," Business History (2017), 7, http://dx.doi.org/10.1080/00076791.2017.1374371.LEÓN-SANZ European Journal for the History of Medicine and Health 79 (2022) 94-119 types: surgical; maternity; children's; mental or psychiatric; anti-tuberculosis; and hospital-shelters.29 periods are distinguished in the presentation of the results: the first includes the refoundation and development of Catholic Church hospitals up to the outbreak of the Civil War (1936-1939); the second covers the evolution 29 Law 37/1962, of 21 July, on Hospitals; see Pilar Leon-Sanz and Pilar Sarrasqueta, "Caracterización de los tipos de Hospitales a través del análisis de la revista de Estudios sobre hospitales y beneficencia," in Al servicio de la salud humana.La historia de la medicina ante los retos del siglo xxi, ed. A. Zarzoso, A. and J. Arrizabalaga (Sant Feliu De Guíxols, 2017), 137-142.refoundation to decline of catholic hospitals spain European Journal for the History of Medicine and Health 79 (2022) 94-119 102 of Catholic Church hospitals almost 600 beds, etc.They also opened the Sanatorio Marítimo in Calafell (Tarragona, 1929, 60 beds) in order to apply new rehabilitation therapies: thalassotherapy, heliotherapy, etc.The statistics of the Order of Saint John of God show a clear expansion in Spain between 1875 and 1914: the number of hospitals managed by the Order increased fourfold and the number of beds thirty-eightfold (Table [69][70]rothers and sisters from institutions in Valencia and Malaga in order to work there (pp.[69][70].35TheSanta Águeda establishment had been a well-known spa after it was built in 1825, and was reopened as a psychiatric hospital in 1882.LEÓN-SANZEuropean Journal for the History of Medicine and Health 79 (2022) 94-119 with Catholic Church hospitals and all other privately-owned hospitals together accounted for 50.2 per cent of hospital establishments.38Catholic Church-owned hospitals enjoyed wide popular support and received private aid, which was very necessary given that the "new" foundations 36 Institution studied by Comes, Cuidados y consuelos.37 Valenzuela and Rodríguez-Ocaña, "Lugar de enfermos," 128; Esteban Rodríguez Ocaña, "La asistencia médica colectiva en España, hasta 1936," in Historia de la acción social pública en España: Beneficencia y previsión (Madrid, 1990), 326-329, notes that charitable hospitals provided a total of around 12,300 beds and municipal hospitals provided another 5,300.38Carasa, El sistema hospitalario, 56.European Journal for the History of Medicine and Health 79 (2022) 94-119

table 2
European Journal for the History of Medicine and Health 79 (2022) 94-119 European Journal for the History of Medicine and Health 79 (2022) 94-119

table 4
Evolution in the number of hospitals and beds according to type of hospital sources: catalogue of public and private hospitals in spain: 31 december 1963 (boe 1966); and 31 december 1970 (boe 1973); national hospital catalogue (1987).42 In 1963, the average number of beds, from smaller to larger, ranged from children's hospitals (42), anti-tuberculosis (44), maternity (60), hospital-shelters (66), surgical hospitals (73), general hospitals (88) and, on a vastly different level, mental or psychiatric hospitals, with an average number of beds of 635.
European Journal for the History of Medicine and Health 79 (2022) 94-119 114 55 Of Belgian origin, the Brothers of Charity, a pontifical institute founded in 1807 by the servant of God, Pierre-Joseph Triest (1760-1836), are present in 30 countries where they care in particular for the elderly and the mentally ill.In 1906, in Belgium, 42 communities, Journal for the History of Medicine and Health 79 (2022) 94-119 consolidation of new Social Security systems.59Moreover, transformations as a result of the introduction of scientific and technical advances and the development of medical specialities. European Standards of care in Catholic Church Hospitals(1963, 1970)source: catalogue of public and private hospitals in spain, 31 december 1963 (boe 1966); leon-sanz, "hospitales de la iglesia," 353.prepared by the author.71 León-Sanz, "La iglesia católica," 192-214.72 Leon-Sanz and Sarrasqueta, "Caracterización de los tipos de Hospitales," 138-139.
European Journal for the History of Medicine and Health 79 (2022) 94-119