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Abstract Throughout history, healthcare, along with diet, has been an essential component of life and a country’s welfare. In particular, a country’s hospital system is a key indicator for analysing the level of welfare achieved by health coverage. From an economic history perspective, the study of hospital systems is relevant since they stem from public and private investment and produce positive externalities by creating employment and stimulating other economic sectors such as construction and health. Spain provides a significant case study for determining the factors of backwardness in the construction of a modern hospital system in a country on the European periphery. Moreover, it also helps us understand how, despite initial obstacles, this system had attained a significant degree of quality by the end of the twentieth century, as confirmed by its current international hospital rankings and even by the phenomenon of health tourism. The study analyses the creation of the Spanish hospital system during Franco’s dictatorship and the transition to democracy. It reveals how the maintenance of a regressive tax system, the use of health policy as political propaganda, and disputes within the political elite of the dictatorship led to an inadequate and fragmented public hospital system, which had to collaborate with the private hospital system, was full of financial holes and tainted by corruption, and remained at the service of privileged groups.