Effects of health care decentralization in Spain from a citizens' perspective.

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.