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Gaceta Sanitaria

Print version ISSN 0213-9111


EPSTEIN, David  and  JIMENEZ-RUBIO, Dolores. What does the decision to opt for private health insurance reveal about public provision?. Gac Sanit [online]. 2019, vol.33, n.5, pp.442-449.  Epub Dec 23, 2019. ISSN 0213-9111.


This study examines individuals’ choice of private health insurance in Spain. Private health insurance choices reveal the attributes of health care most highly valued by the population, and the perceived responsiveness of the public system in delivering those preferences.


The paper exploits the 2004, 2009 and 2014 waves of the national Health Barometer survey, examining the health insurance choice separately for the general population and a small but influential sector of elite public-sector employees who can opt out from the public health system (civil servants).


Public healthcare is a highly regarded provider in terms of technology and doctor training, even by those who chose private health insurance, but falls short in terms of amenities such as comfort and speed of attendance. These findings confirm well-known strengths and criticisms of the public system. However, the study also finds that citizens are concerned about the performance of the public sector in key domains of health system responsiveness, such as personal contact and information and these concerns also influence their decision to opt for private provision. Finally, civil servants, even the minority who opted for public provision, tend to have a lower opinion of the public health service than non-civil servants, especially in terms of personal contact, information, primary care and specialist care.


These perceptions and concerns of the public about the performance of the public health service will be of interest for policy makers and should be investigated further.

Keywords : Spain; Health services; Health insurance; Satisfaction; Civil servants; Attributes of healthcare.

        · abstract in Spanish     · text in Spanish     · Spanish ( pdf )