chapter twenty two Spain: A case study on diversity of DRG use – The Catalan experience Francesc Cots, Xavier Salvador, Pietro Chiarello, Montse Bustins and Xavier Castells 22.1 Hospital services and the role of DRGs in Spain 22.1.1 The Spanish health system The Spanish 1978 Constitution granted all citizens the right to health protection and care, and this was confirmed by the 1986 General Health Care Act (GHCA). The GHCA specified the basic features of the Spanish health care system, such as public financing and universal access to public health care services free of charge at the point of use. Furthermore, it recognized the devolution of health care responsibilities to the Autonomous Communities (ACs), that is, to the Spanish regions, which is an important characteristic of the Spanish health care system today. In 2007, total health expenditures amounted to €1980 per capita per year, which corresponds to 8.4 per cent of gross domestic product (GDP) (European Commission, 2011). Public expenditures (mostly financed through general taxation) are the most significant source of finance in the Spanish health system as they account for roughly 72 per cent of total health expenditures. Household out-of-pocket expenditures account for about 22 per cent of total health expenditures and are mostly spent on services not covered by the public system (for example, dental care and services provided by private specialists). In addition, an increasing share of the population (25 per cent in 2007) holds private health insurance coverage (López Casasnovas, 2008), which pays for care provided in the private sector.