The aim of this article is to analyze the impact of the decentralization of the public national health system in Spain on citizens’ satisfaction with different dimensions of primary and hospital care. Using micro-data from the Health Barometer 1996–2009 and taking advantage of the exogeneity of the different pace of decentralization across Spain using a difference-in-differences strategy, we find that, in general, decentralization has not improved citizens’ satisfaction with different features of the health services. In our base model, we find that there are even some small negative effects on a subset of variables. Sensitivity analysis confirms that there is no empirical evidence for supporting that decentralization has had a positive impact on citizens’ satisfaction with health care. We outline several possible reasons for this.
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Data computed from OECD statistics on National Accounts, General Government Accounts and Government Expenditure by Function.
See, for example, Rico and Costa-i-Font , with a very positive evaluation of decentralization, and Braña and Serna [10, 11] and Braña . Particularly, Braña and Serna [10, 11] and Braña  analyze and compare, policy by policy, the level to which certain competences should be transferred according to economic theory and the Spanish case, pointing that in most cases decentralization has been driven by political issues.
A chronology of the implementation of new forms of management across regions can be found in Ruane et al. .
The Spanish case is a good example of such potential problem. Among the 17 Autonomous Communities, some are small in size and with few inhabitants (such as La Rioja, with 5,000 squared kilometers and a population slightly over 300,000); some are small but very populated (notably Madrid, with 8,000 thousand squared kilometers and almost 6.5 million inhabitants), some large and sparsely populated (Castile-Leon, a region with 94,000 squared kilometers, approximately the size of Portugal, and 2.5 million inhabitants), etc. The intention has been that all regions could offer almost all kinds of health services and treatments, irrespective of their sizes or demographic and economic characteristics. It seems clear that decentralization has not been carried out keeping in mind an optimal size of jurisdictions, as regions are extremely diverse. Patients have the right to be treated in other regions if the treatment is not available in theirs. The same applies to temporary Spanish visitors to other regions. However, in practice, the different mechanisms of compensation have not worked well, which might explain some obstacles for being treated outside the region of origin reported by the media in the last years. In order to fix that, when a new compensating tool was established for this purpose was established in 2012.
See, for example,  for a review of theoretical and empirical research on decentralization of health care.
For example, among others, the works of Del Pino , Calzada and Del Pino [12, 13], Del Pino et al.  and Díaz-Pulido et al.  analyze satisfaction of citizens with several public policies. The work of Díaz-Pulido et al.  is of particular relevance to our work. These authors, after studying the determinants of citizens’ satisfaction with education, health and pensions, conclude that there are differences in satisfaction with public services among different regions, even after controlling for the characteristics of the respondents, especially in those services run by the Autonomous Regions. Regarding health care, one can highlight the work of Álvarez and Ruiz , which analyzes the valuation of the National Health System by citizens from 1995 to 2004.
Nevertheless, we have to keep in mind that the bulk of the decentralization process occurred in 2002.
See, among many others, the collective work of Saltman et al. , the reviews of Jiménez-Rubio et al.  and Kolehmainen-Aitken , the works of Bossert et al. , Arreondo et al. , Vargas  and Martínez and Rodríguez-Zamora  for Latin American countries, the analyses of some African experiences by Jepsson and Okuonzi  and Akin et al. , Tang and Bloom  on China, Jiménez-Rubio et al.  and Zhong  on Canada, Ferrario and Zanardi  on Italy and Cantarero and Pascual  on European Union countries. We comment on the results of these studies in the “Results” section.
In September 2012, the Central Government introduced some limitations to the rights to receive health care of illegal migrants in the country.
Recently, in the context of the fiscal crisis, a new copayment in drugs was introduced by the governments of Catalonia and Madrid (although the Constitutional Court has temporarily suspended its application until it makes a definite decision on its legality) and the Central Government decreed an increase in cost-sharing for drugs and other services such as prostheses and ambulance services.
There is an additional wave for 1995, but it has not been included in the analysis because some of the regional control variables have only been available since 1996.
Since not all waves in the database include information about whether an interviewed person is a user of the public health care system, we do not consider this variable in the analysis. Anyway, the perspective of non-users is also relevant for several reasons. First, they might use less the system because they are unsatisfied with it. Second, one might not be a user but possess a relevant knowledge of the system because of health problems of relatives, for instance. Third, collaboration between public and private producers is increasingly frequent in Spain, with many patients enjoying private care that is publicly funded. Fourth, as long as preferences as well as support of the whole population is considered a relevant variable for decentralization, satisfaction of the whole population—and not only of the most intense users—is a relevant issue.
We do not control for features like the different ways of organizing health care (for example, contracting out, private-finance initiatives, etc.) because our focus is on the average effects of decentralization, as usual in policy evaluation. Particularly, as mentioned, the possibility of introducing innovations consisting in new forms of organization is highlighted as one of the main advantages of decentralization . In addition, since these types of innovations are indeed starting to be introduced by some regions after receiving competences in health care, such policies are outcomes of the decentralization and cannot be considered as exogenous to the devolution process. In this respect, they can be seen as what Angrist and Pischke [5, p. 63–66] call ‘bad controls’ (introducing variables that are outcomes of the treatment variable), which can yield biased estimates. In this respect, we proceed as the standard literature evaluating the impact of decentralization summarized in the article.
Furthermore, it is not possible to use a model like an ordered logit during the whole period of analysis: the scale change implies that, before the scale change, it only comprises 8 available values, while the change means implies 10 values can be chosen thereafter. Therefore, the number of alternatives—to be used by an ordinal logit model—is not constant, making the ordered logit not applicable to the whole period. Nevertheless, we have estimated an ordered logit model for the period 2001–2009 (during which there is no scale change) for the base model and the results are absolutely identical to those obtained using OLS.
There is another reflection that is worth mentioning and according to which one should not care very much about adjusting the errors once the variance associated to individuals is considered. While interviewed individuals represent a sample of population of each region, Autonomous Communities are not a sample of the population of clusters: they are the population of clusters itself. Therefore, as suggested by a very well-known article of McCloskey and Ziliak , one should wonder if statistical inference is needed (of course, we refer to inference with respect to the clusters/regions; individuals continue being a sample and inference regarding them is needed). In other words, all randomness in the database is associated to individuals.
For instance, Khaleghian  finds no effect of decentralization on immunization in middle-income countries, the study of Andrei et al.  does not detect any significant impact of the regional share of spending on either infant mortality or life expectancy in Romania, the work of Vargas  reports that centralized health care providers perform better than decentralized ones in rural areas in Mexico, and Martínez and Rodríguez-Zamora  point to the lack of impact of decentralization on different health indicators in the same country. An important part of the empirical literature on this issue concentrates on low- and middle-income countries using infant mortality rates as the dependent variable (see the review of Jimenez-Rubio ). Such literature concludes that there is a negative impact of decentralization of health on infant mortality rates. This impact is higher the lower the per capita income of the country. In fact, some authors  limit the positive impact of decentralization to low income countries (in middle income countries the impact is negative). In contrast, the results for Uganda of Akin et al.  suggest that for reasons including inter-district spillover benefits of public goods decentralization does not necessarily increase social welfare. For developed countries (European Union member states), Cantarero and Pascual  find similar results using infant mortality as dependent variable. Similar conclusions are reached for Canada by Jiménez-Rubio . In any case, as stated by Nolte and McKee [53: p. 10], it has to be acknowledged that the general reduction in infant mortality rates and the low level of variation achieved limit the “ability to compare health system performance using mortality data at the aggregate level,” with infant mortality being therefore a less than advisable indicator for this type of analysis. For instance, in the case of the works of Cantarero and Pascual  and Jiménez-Rubio , no regional-specific time trend is included, so it is possible that more decentralized regions would have performed the same without decentralization if they were improving at a different pace than the others. In the Spanish case, for example, the evolution of infant mortality (under 5 years old) in the period 1960–2011 closely follows a logarithmical time trend (R ² = 0.98) with slightly over the fitted function in the first part of the period 1962–1980 and slightly under it from 1980 to 2004 (the same can be said for life expectancy, this time with a linear trend, R ² = 0.99). In other words, the reduction of infant mortality rates in Spain is essentially explained by the time trend. Finally, in their analysis of decentralization of health (from a finance perspective) in three Latin American countries, Arreondo et al.  show the existence of strengths and weaknesses that make it difficult to judge decentralization as a success or failure.
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We thank the Centre for Sociological Research (Research Grants 2011 edition). Antón and Fernández Macías also acknowledge financial support from the Spanish Ministry of Science and Innovation (project CSO2010-16413). An earlier version of this article was presented at the XXXVII Simposium of Economic Analysis in Vigo (Spain) on 14–16 December 2012. We are grateful for the comments from four anonymous referees that contributed to substantially improving the paper.
See Table 7.
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Antón, JI., Muñoz de Bustillo, R., Fernández Macías, E. et al. Effects of health care decentralization in Spain from a citizens’ perspective. Eur J Health Econ 15, 411–431 (2014). https://doi.org/10.1007/s10198-013-0485-0
- Health care
- Citizens’ satisfaction