Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 281 Ferran Sabaté Reial Acadèmia de Medicina de Catalunya/Societat Catalana d’Història de la Medicina (Spain) The Evolution of the “Catalan Health Model” in the Twentieth Century. Sources for its Study Abstract This paper presents an overview of relevant sources for the study of the development of the “Catalan Health Model” during the twentieth century, and the ideas and institutions influencing its evolution. The paper indicates that it is a health system configuration where the core is public universal health assistance, complemented by the private health sector. Also, that it is the result of a dynamic traditional mixed model organization. The sources for the study of this health system are scattered in public or private archives and published reports. Due to the disruptions of war and periods of dictatorship, the model has gaps or becomes disjointed. Keywords: Catalan Health Model; Development; Sources of information Corresponding author: e-mail: drsabate@yahoo.es Received 21 September 2020 - Accepted 18 November 2020 This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non-Commercial-No Derivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-comercial re-use and distribution, provided the original work is properly cited, and is not altered or transformed in any way. mailto:drsabate@yahoo.es http://creativecommons.org/licenses/by-nc-nd/4.0/ Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 282 1. Introduction The nineteenth century is the origin of contemporary western society, with important social and economic changes that transformed all aspects of society – its institutions and organizational models. The industrial revolution, the urbanization of the population, the materialist and evolutionary concepts in the field of medicine, and increasingly, technology, changed the perspective of human disease as well as the delivery of health services for a group of populations (Corbella and Calbet 1973). The last two decades of the nineteenth century, and the first two decades of the twentieth century initiated the transition from traditional charity assistance, to a public and private coordinated network delivery of health care (Sabaté 2017). The Catalan Health Model, in this context, is the dynamic result of a variety of factors, modeling the medical and sanitary organization of Catalonia (Reventos 1996). It has been defined as “a mixed sanitary model, that integrates a unique network of public utilization of all the sanitary resources from public and private ownership, that follows a secular tradition of entities (religious, mutualities, foundations, cooperatives, consortiums), historically oriented to deal with health and social problems” (Moreta 1975; Pérez-Bastardas 2014). It is a system with public financing and universal coverage, that provides free access to health care for all Catalan citizens. This model is based on standards of equity, efficiency, sustainability and citizen satisfaction (Vidal 2014). In the historical evolution of this system we find three stages. The first one, in the first third of the twentieth century, was characterized by the continuity of private medicine, the public beneficence (Asistencia Publica Domiciliaria) by municipalities, benefit hospitals and mutual entities; and by the beginning of health planning and development by the regional self- Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 283 government and health professionals (Sabaté 2015a). The second one, in the second third of the twentieth century, saw the emergence in Spain of the Seguro Obligatorio de Salud or Compulsory Health Insurance created in 1942 (Rumeu de Armas 1943) with support from the Spanish Ministry of Labor and inspired by the Bismarck German system. In this second stage Ciudades Sanitarias or “health residences” (so named to avoid the word hospital which was unpopular) and facilities for out-patient consultation with public funding expanded. Specialized private medicine, though, persisted. In Catalonia, a private cooperative health system was developed, and hospital regionalization was proposed. Finally, in the last third of the twentieth century, the Insalud (for the public health services) and the Inserso (for the public social services) were organized in Spain in 1978. In 1986 the General Health Law was issued, and created the National Health Service, inspired by the British health system. In this general framework of changes in the Spanish hospital system, for the particular history of the development of the Catalan Health Model, we should consider or distinguish three periods: 1) initial self-government by the “Mancomunitat” (commonwealth) and the Generalitat of Catalonia (autonomous government) between 1914 and 1939; 2) Franco’s dictatorship period (1940-1975); and 3) the new self-government period with the democratic Generalitat of Catalonia after the 1980s. Each period represents a step in the evolution of the model, influenced by social, technical, political, and economic factors. Important protagonists in the development and support of the Catalan Health System during the twentieth century were the municipality of Barcelona (Roca 1991), and the Diputació, with their programs and institutions acting as a complimentary provider during the periods of self- government, and as a substitute public authority during the dictatorship times. Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 284 2. Background The analysis and study of the Catalan Health Model could be performed from different perspectives: anthropological, economical, legal, historical, institutional, and comparatively with other models. Each approach has its own sources and methodology (Comelles 2013) and has mainly been studied from a historical perspective. The particular history of medicine in the region should be the beginning of any research about this model (Corbella 2014), as it gives a general overview of the long-term evolution, and provides clues for an objective interpretation of the data. After that, particular topics can be considered: biographical, clinical, economical, legal, sociological, technological, etc. Since the backgrounds of medical institutions in Catalonia are diverse, even during this century, the sources for these studies are different, relying on the origin: foundation, public, private, cooperative, municipal, religious, mixed, etc. Each of them has its own legal status, economic maintenance, clinical and administrative records, etc., giving more or less relevance to the qualitative or quantitative aspects of their functioning. Due to legal changes from economic crises, wars, changes in the property or administration of the institutions, the continuity and uniformity of the registers are not guaranteed, making the comparisons difficult. Another concern is the preservation of this information (Martínez Vidal 1998). Until recently, health information was written and saved in a hard-copy paper format, taking up limited space; subsequently, some of the records were discarded. Sometimes, these materials have been discovered in antique shops, or in a second-hand markets. The best documented health institution along 600 years of continuous service, is the “Hospital de la Santa Creu i Sant Pau” in Barcelona, owned and managed without interruption by the Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 285 municipality and the cathedral chapter, by a governing body named the Very Illustrious Administration (Molt Il·lustre Administració in Catalan or MIA). Their registers are split between the Biblioteca de Catalunya or Library of Catalonia (until the nineteenth century) and the historical archive of the hospital for contemporary data (catalog available by Internet). Their rich sources of data include information regarding the name, age, sex, origin, economic status at admission and health problem of the patients. Information on maternity and orphans; psychiatric and old people are accepted. It also contains information about daily menus and diets. Regarding the institution, its financial records include: donations, inheritances, payments, salaries and other income and expenses. Other institutions owned by municipalities may find registers in the archives of the institution or the municipality and district (“comarcal”) archives. For programs and institutions created or sustained by the Mancomunitat, or commonwealth of Catalonia, researchers can find primary and secondary sources at Arxiu Històric de la Diputació de Barcelona (Mancomunitat de Catalunya 1923a and Sabaté 1993). Private institutions, as well as some personal papers can be found in the archives and libraries of Arxiu Nacional de Catalunya, Biblioteca de Catalunya, Museu d’Història de la Medicina Catalana, Fundació Uriach 1838. The turmoil of the Spanish civil war and the repression of individuals and institutions that followed, destroyed, exploited and stifled documentation. Religious institutions were under assault; the library and publications of the Institut de Fisiologia were burned in the cloister at the Medical School, and the registers of the Sindicat de Metges de Catalunya or Union of Physicians of Catalonia were confiscated and disappeared (Sabaté 2020). Information regarding the creation, development, and activity of the Seguro Obligatorio de Enfermedad or Compulsory Health Insurance from 1942 are in official reports from the Spanish Ministry of Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 286 Labor and Social Security, the National Social Security Institute and other Spanish agencies for the period of Franco’s dictatorship (El Mundo del Seguro de Vida 2020; Ministerio de Inclusión, Seguridad Social y Migraciones 2020). Since the last quarter of the century, under the self-government of the Generalitat de Catalunya, the official information on health organization and legislation comes from the Conselleria de Salut or Department of Health (Diari Oficial de la Generalitat). Some institutions issue annual summaries of their activities, foundations must present an annual report, professional organizations give official information via announcement or bulletin. The activity and position of scientific societies can be followed in their journals and monographs. 3. Biographies The influence of some personalities in the development of a particular therapy, medical technology, organizational model or health institution is clearly documented throughout history. That is the reason why biographies are a relevant source of information, more qualitative than quantitative. Unfortunately, we do not have many in the field of health (physicians or pharmacists), and the scope is often not comprehensive enough. Some are mentioned in the bibliography: Dr. Jaume Aiguader (Poblet 1977), Dr. J. Alsina i Bofill (Casassas 1996), Dr. Manuel Corachan (Marí 1981), Dr. A. Pi i Sunyer (Various Authors 1979), Dr. Cinto Reventos (Reventos 1984), Dr. Josep Trueta (Rodrigo 1977), and others. Additionally, we have auto-biographic productions, with published (Broggi 2011; Trueta 1978; Ylla-Català 2018) or unpublished materials, in the hands of the family (Dr. Joaquím Ramis i Coris), in public archives or private libraries. Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 287 Sources of personal and professional information include dictionaries and encyclopaedias (Calbetand Corbella 1981-83). Directories, guides or Vademecums of medical practitioners produced by professional organizations, scientific institutions, or with commercial purposes (Metges de Catalunya i Balears. Any 1930. Barcelona, Publicaciones López-Brea), give some information regarding: address, specialty, year and place of work, etc. Also, catalogues of medical devices, containing useful information regarding the technological development in medical fields (in Museu d’Història de la Medicina de Catalunya for instance) cannot be forgotten. 4. Medical institutions Only sources about general hospitals during the XX century will be noted in this section. Private, specialized institutions are documented in other contributions of this issue. Hospitals have a long tradition in Catalonia since the Middle Ages (Salmerón 2001). An important aspect has been their continuity until now. This allows a long term perspective and allows for comparisons (Corbella and Xifró 1996), and to follow-up in some aspects of their life. Regarding their origin, there are a variety of status points: royal, municipal, religious, private foundation, mutual or cooperative. By the end of the XIXth century, the accelerated process of urbanization in Barcelona produced a clear lack of hospital beds. This was pointed out by the hygienists, and social movements. Some provisional actions during epidemics were undertaken when continuity was established (Ausín 2002). The enlargement and modernisation of Santa Creu hospital in Barcelona had been proposed and discussed since the mid-XIXth century, to host the patients and the medical students appropriately. At this time, the Hospital del Sagrat Cor was created in Barcelona (Agustí 1991) by a group of charitable bourgeois Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 288 Roman Catholic women and the assistance of the Bishop of Barcelona. It started as a surgical centre, with a small group of qualified professionals who quickly achieved prestige in different specialities. The psychiatric Institut Pere Mata in Reus, was opened in 1900, with healthy gardens and pavilions, and a modern philosophy in the treatment of mental diseases (Garcia Sisó 1992). It was built and managed by a private society. L’Hospital del Mar or d’Infecciosos in Barcelona, was created in 1905 by the municipality to isolate and treat patients with contagious diseases. The second half of this century it evolved into a general hospital treating different types of diseases (Venteo 2015). The Hospital Clínic i Provincial and Facultat de Medicina of the Universitat de Barcelona opened its doors in 1906 after some years of discussion between central and provincial administrations regarding the financial responsibility to furnish and equip the centre and pay the bills of the patients. It was a public and charitable institution in the beginning, until the 1970s when it changed its legal and organizational model to a tertiary high tech medical, research and educational institution (Corbella 2006). The medical and social problems of the tuberculosis outbreak had a very big impact on the health care system at the turn of the new century (Garriga 1915). The inactivity of central administration, moved in 1911 the Patronat de Catalunya per a la Lluita contra la Tuberculosi, with the economic support of the Caixa de Pensions per a la Vellesa i Estalvis, to open the sanatorium of “Torre Bonica” in a healthy rural area near Terrassa (Calbet Camarasa 1988). The Mancomunitat de Catalunya, created in 1914, soon started planning the development of public services for poor, mentally ill patients and the construction of maternities. Additionally, the “Casa Maternal Catalana” was built in Barcelona. It was planned as the cornerstone of a comprehensive maternity and children services network (Farré 2003). The “Clínica Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 289 d’observació i Hospital mental” in Santa Coloma de Gramenet, was opened in 1930 (Bernardo 1985). In 1917, the “Quinta de Salud La Alianza. Mutualidad de Previsión Social” opened its doors in Barcelona. Created by the “Sociedad La Alianza. Hermandad de Camareros de Barcelona”, to give medical services for their associates. Soon the quality of their services caught the attention of other social and professional groups. It experienced an important growth, with the establishment of other clinics in different areas of Catalonia.1 A Red Cross Hospital was founded in Barcelona in 1920, that mainly attended to wounded soldiers who returned from the war in Africa. After the Spanish civil war, it became a centre for injured labour workers and surgical specialties (Coll 2000). From 1980 onward, it became a general hospital. The hospital Plató, founded in Barcelona in 1925, was known also as Clínica Medico Quirúrgica Sant Gervasi or Institut Policlínic. Promoted by a group of five physicians with the aim to provide high quality medical services (Casares and Fuentes 2001), it was developed as a policlinic, with teaching activities. All of these institutions, regardless of ownership, had been providing health care to the public sector, with different modalities of agreement during this century. In the second half of the XXth century, after the Spanish civil war with the onset of the “Seguro Obligatorio de Enfermedad,” the construction of new hospitals named “Residencia” or “Ciudad Sanitaria” was planned by the central government, to avoid the bad memories and reluctance of the citizens to the services provided by hospitals in the past. Some of these hospitals were built in Catalonia between 1950 and 1975, in Barcelona, Tarragona, Girona, Hospitalet del Llobregat, Badalona and Terrassa, to care for patients sent by physicians from the Seguro Obligatorio de Enfermedad only. 1 Arxiu Nacional de Catalunya, Fons “La Alianza”. Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 290 5. Research Institutions In the XXth century, medical research became public, and an integral part of the regional program of development and modernization setup by the Mancomunitat of Catalonia (Barbany and Granados 1978). The “Societat de Biologia de Barcelona,” founded in 1913 by the Secció de Ciències of the Institut d’Estudis Catalans, was the first step in developing autonomous biological research.2 The Mancomunitat of Catalonia was established in 1920, in the School of Medicine the “Institut de Fiologia” (Corbella 2009), and was led by professors August Pi Sunyer, and Jesús M. Bellido Golferichs. They established scientific relationships with prominent international physiologists as Walter B. Cannon, and Bernardo Hussay. One of its members, trained in Canada, did pioneering work with insulin. Unfortunately, the archives of this institute were burned publicly in the cloister of the Medical School at the end of Spanish civil war. By the end of the century, clinical research was done in hospitals with the creation of research institutes to benefit the laboratories personnel, and patients. Their work can be followed in the scientific journals of the different specialities, congresses, and medical societies. The development of the local pharmaceutical industry has had important significance. Since the last century, some pharmacists working in their laboratories, prepared and sold their own pharmaceutical formulas (Morell 1996). They transitioned from workmanship to industrial production (Bosch, Fernandez and Baños 2007). This has provided a strong health and economical instrument, mainly during the autarchic period of the Spanish economy (Pérez- Bastardas 2002). Some of the drugs that were invented became bestsellers, and are the origin of the local pharmaceutical industry. Some of these formulas became commercial brands with 2 Their works are published in the journal Treballs de la Societat de Biologia de Barcelona. Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 291 great success (Sinca 2011). Biographies of these enterprising pharmacists and physicians show the contribution and commitment with the system (Grifols 2009). One of these protagonists was the “Laboratorios Dr. Esteve” (Sinca 2015), one of the first in Europe to obtain penicillin, and was visited by Alexander Fleming. The relationship between research, health industries, and health systems has been part of the environment were the Catalan Health Model has developed. 6. Professional institutions The professional institutions are bodies with influence in the medical practice and the organization of the health system. In Catalonia there are two main entities that strongly influenced and oriented the Health Model, giving them its particularity, based in the secular tradition of transaction and agreement between the parts. Their participation gives stability, continuity and social recognition to the Catalan Health Model. The “Academia de Ciències Mèdiques” is a scientific society created by a group of medical students and professors 150 years ago to introduce the experimental knowledge in the study and practice of medicine. Without official recognition or assistance, they setup a laboratory for the practical study of Anatomy, Physiology, Microbiology, and Therapeutics. They also organized practical courses for students and practitioners, as a compliment to training with subjects not treated in the official university programs. They also established a library to be updated with journals from France, Germany and Italy. This influence and spirit of innovation has been clear over time in Catalan medicine, allowing them to be in permanent contact with the latest advances in Europe, in clinical practice, as well as in organization of assistance (Calbet 2001). We do not have a comprehensive history of this core institution. It is possible to follow this Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 292 activity throughout the official journal digitalized “Annals de Medicina,” as well as in the registers of each specialized society that conform this entity (Martínez and Pardo 2003). The second important professional entity with real and sustained impact in the Catalan Health Model is the “Sindicat de Metges de Catalunya” or Union of Physicians of Catalonia (Martín 2020), created in 1920, a hundred years ago. In fact, it is the oldest medical union or syndicate in Europe. It was promoted by Ramon Pla i Armengol, an active physician, and successful entrepreneur with cultural and political involvement in the fields of catalanism and socialism.3 The aim was to protect the material and ethical interests of their affiliates in the liberal and employee practice of medicine. But since the beginning, concerns were also in social and collective medicine, and safeguarding public health interests. During this time, they had the ability and success in harmonizing both rights: caring for the interests of the physicians as well as the patients (Danon 1974). Its influence inspired and became pivotal in the construction of the Catalan Health Model (Sabaté 2020). 7. The elaboration of a health model The first social insurances in rural and urban areas (Baselga 1957) appeared in Catalonia by the second half of the XIXth century. In the field of health, some societies, brotherhoods, and trade unions collected money regularly from their constituents to pay the medical or pharmacist expenses of their associates; or contracted physician or pharmacist services for their members. This existing social organization became an ideological background for the progressive 3 Library Universitat Autònoma de Barcelona, Fons Ramon Pla i Armengol. And archive of Mutual Médica in Barcelona. Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 293 elaboration of the modern Catalan health system. Within the Catalan health system, there are three distinguishable stages. The creation of the Mancomunitat of Catalonia in 1914 (Balcells 2015) was the first step of self-government exactly 200 years after the abolition and submission to Spanish monarchy and was the beginning of the contemporary Catalan health model. The Mancomunitat drafted the model and began the organization (Sabaté 1993). It moved from merely being legislative regarding outbreaks of epidemics, to mobilizing public resources to prevent or fight infectious or parasitic diseases. It transformed the beneficence, and charity in public social services. Malaria, tuberculosis, maternity, and mental illness were the focus fields of interventions. During its short lifecycle (only 10 years), it could not fulfill all of the obligations to the programs and materialise all of the needed initiatives and endeavours. In this first stage, we can identify two sub-periods. First (1914-1919), the health intervention of the Mancomunitat used three instruments: a) direct intervention, as in the creation of the “Casa Maternal Catalana” in Barcelona or the “Clínica d’observació i Hospital mental” in Santa Coloma de Gramenet; b) economical donations to existing health or social private institutions giving service to the community; c) public health initiatives developed throughout the Institut d’Estudis Catalans, a scientific official body, as the interventions to control malaria and tuberculosis (Mancomunitat de Catalunya 1922). The second period (1920-1924) is characterized by the: a) effective control over public health resources (provincial and district hospitals, orphans and poor or senior houses); b) subsidies to private health or social institutions, with control of services provided (Manicomi of Sant Boi; La Alianza, etc); c) development of a scheme of health districts: “Divisió sanitària de Catalunya” and “Brigades sanitàries” (Mancomunitat de Catalunya 1923b). Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 294 In 1922 an important event took place, “Conferencia Nacional del Seguro de Enfermedad, Invalidez y Maternidad” in Barcelona. In this meeting, the Sindicat de Metges de Catalunya presented a proposal known as “Sistema català de l’assegurança de malaltia”,4 trying to do a synthesis between social and liberal practice of medicine. It was based on three related concepts: 1) Autonomy for the people: patients and doctors; 2) Coordination between the health institutions, and 3) Social solidarity to finance the system. The proclamation of the Second Spanish Republic in 1931 brought the second period of the Catalan self-government. The medical community, under the leadership of the Sindicat de Metges de Catalunya, offered to the new government a comprehensive health organizational model for Catalonia (Sabaté 2020). It followed and developed the scheme planned by the Mancomunitat, but with more detail (Fernández Pellicer 1932). The Generalitat assumed all the health competences in its territory (Hervàs 2012). The health law of 1933 adopted most of the proposals made by the Sindicat. It defined three levels of attention: primary for the proximity services, secondary for intermediary processes, and tertiary to manage the complexity. By 1934, the regional health ministry presented an administrative health model based in the municipalities, refused by the Sindicat. At a Conference in Zaragoza in 1935, they tried to establish the medical assurances in Spain. The Sindicat presented its position named “Doctrina Mèdica Catalana de l’Assegurança Social de Malaltia”, synthesized in ten points, harmonizing liberty with solidarity (Sabaté 2015b). It was rejected by the majority of Spanish medical organizations (Rodríguez and Ortiz 1988). 4 This proposal was presented by Dr. Josep Girona i Trius at the National Conference on Disability, Malnutrition and Illness Insurance. See Butlletí del Sindicat de Metges de Catalunya, 30, November, 1922. Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 295 During Franco’s dictatorship, the Seguro Obligatorio de Enfermedad (SOE) was established in 1942, for workers and their families based on the Bismark model with medical assistance provided by physicians paid by salary (Raventos, Garcia and Piqué 1991). This system was the opposite of the previous proposals of Catalan medical professionals and institutions. Nevertheless, by 1957, doctor Josep Espriu Castelló launched “Assistència Sanitària Col·legial” in Barcelona following the social spirit of the Catalan society, to provide medical services under the cooperative model of functioning. Late in 1969, the need to rationalize and sectorialize the existing hospitals in Catalonia was presented again by a group of experts (Soler et al. 1969). During the last quarter of the XXth century the democracy brought a new period of self- planning and management of the health sector to Catalonia, as well as in other regions of Spain. Immediately, the “Congrés de Cultura Catalana,” an organization raised ad-hoc by the Catalan society to analyse and create proposals in different fields for the new period, and new situation (Rovira 2020), spouted a group (Àmbit de Salut) of citizens and health professionals that after a free discussion, drew-up an organizational proposal to adapt the former model to the new situation, in accordance with the local idiosyncrasy and tradition. In 1976, a group of medical and economic professionals, related with the Partit Socialista Unificat de Catalunya (PSUC), made the proposal to create the National Health Service (Acarin et al. 1977). Other ideological options of reform the ongoing health system where presented (Solé Sabaris 1978). Also, the Col·legi de Metges de Barcelona, setup a working group called the “Gabinete de Asesoría y Planificación Sanitaria” (GAPS), to discuss and advise the Generalitat on how to organize the provision of medical services. The “Xè Congrés de Metges i Biòlegs de Llengua Catalana” held in 1976, had a section named: “Funció Social de la Medicina,” where the past and future Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 296 orientation of the Catalan Health Model was discussed in detail. First, the transition from individual to collective medicine; second on what is health?; third on present situation, and fourth about perspectives for the future (Acadèmia de Ciències Mèdiques de Catalunya I Balears 1978). As explained in other contributions to this special issue, in 1978, the government of Catalonia started the elaboration of the “Mapa Sanitari de Catalunya” to asses and plan the model, with two chapters: 1) Present the health situation, analysing: health status; ecological environment; health resources; legal and administrative situation; economical structure and Catalan health resources. 2) Territorialisation project: health areas and sectorialization; territorial health administration; health endowment of the areas (Generalitat de Catalunya 1980; Coca 1980). The legal assumption of the health competences by the Generalitat de Catalunya was in 1981, after 5 years of proposals and planning by the civil and political society. The first decision was the creation of the Institut Català de la Salut (ICS) in 1983 (Diari Oficial de la Generalitat de Catalunya, July 7, 1985), as the main provider of public health services. The second important organizational and legal step was in 1985, by: A) the order of “Reforma de l’Atenció Primària” (Primary health care reform), giving them the category of first and main contact of the citizens with the health system; and B) the creation of the “Xarxa Hospitalària d’Utilització Pública” (Hospital network of public use), as a functional incorporation of private hospitals in the public use network (Diari Oficial de la Generalitat de Catalunya, July 15, 1985). These strong decisions characterize the contemporary Catalan Health Model, stressing the importance of the primary health care (preventive and community oriented), and the functional use of all health resources independent of the ownership. In 1990 (Diari Oficial de la Generalitat de Catalunya, July 9, 1990) the option of different providers for Primary health care: was introduced as Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 297 Professional Societies or “Empreses de Base Associativa“(EBA), an association of nurses and doctors as a self-managed enterprise or cooperative society; also, the possibility of a Health enterprise. A cornerstone in the Catalan Health System was the Law 15/1990 (Diari Oficial de la Generalitat de Catalunya, July 30, 1990; Vallribera 2015) called “Llei d’Ordenació Sanitària de Catalunya” (LOSC), that created the “Servei Català de la Salut” (CatSalut) (Generalitat de Catalunya, 1992), and distinguished three levels of responsibility: 1) health planning to departament de Salut; 2) financing services to Servei Català de la Salut; and, 3) provision of health by providers. It establishes a clear separation of functions in the Catalan Health Model: The Parliament assigned the budget; the Department of Health designed the Health Plan; the Servei Català de la Salut distributed and paid the services (Brosa and Agustí 2010); the providers gave the health services. The CatSalut contracted health services with different providers, according to the needs of the population (De la Puente 2010). In 1993, “Plans de Salut” (Health Plans) was initiated and issued for specific problems that impacted the population such as: oncology, immigration, etc., called “director plan” for each problem, which is evaluated every five years. Also, the “Mapa sanitari, sociosanitari i de salut pública” was issued 1993(De la Puente and Fusté 2008; Generalitat de Catalunya 2008), with the creation of seven “Health Regions” to approach the management of the needs of the population. 8. Conclusions The Catalan Health Model in the XXth century is the result of a long autochthonous tradition, influenced by many factors in different proportions, as presented in this paper. In short, it is a public and universal system characterized by the coexistence of private institutions giving Volume 6, Number 1, 281-305, January-June 2021 doi.org/10.1344/jesb2021.1.j090 298 subsidiary public assistance. It establishes a clear difference between: the administration, the provision and the financing of services. Delivered under the premises of: equity, efficiency, sustainability and satisfaction. It stresses the objectives of: coordination, decentralization and citizens participation. The sources for the study of Catalan Health Model are of two types. Primary sources can be searched in: A) Arxiu Històric de la Diputació de Barcelona, Reports del Consell Permanent a l’Assemblea de Diputats de la Mancomunitat, Crònica Oficial de la Mancomunitat de Catalunya (1920-1923), L’Obra realitzada 1914-1923 for the period of the Mancomunitat de Catalunya; B) Arxiu Nacional de Catalunya, Biblioteca del Pavelló de la República-Universitat de Barcelona, Butlleti Oficial de la Generalitat de Catalunya, for the period of Generalitat and Civil War. Boletín Oficial del Estado; C) Archives from: Instituto Nacional de Previsión, Col·legi Oficial de Metges de Barcelona, Fundació Dr. Espriu, for the Franco’s dictatorship. D) Acadèmia de Ciències Mèdiques i de la Salut de Catalunya i de Balears, Fundació Congres de Cultura Catalana, Col·legi Oficial de Metges de Barcelona, Diari Oficial de la Generalitat de Catalunya, Arxiu del Parlament de Catalunya, for the last period. 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