The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis

Document Type : Original Article

Authors

1 Global Public Health Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK

2 Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece

3 School of Social Sciences, Panteion University of Social and Political Sciences, Athens, Greece

Abstract

Background 
Fiscal decentralisation (FD) is a widely implemented decentralisation policy consisting of the allocation of pooling and spending responsibilities from the central government to lower levels of governance within a country. In 2001, The Italian National Health System (Servizio Sanitario Nazionale, SSN) has introduced a strong element of FD, making regions responsible for their own pooling of resources and for their budgets. Despite the relevance, only few studies exist on health sector-FD in Italy, mostly looking at the effects of FD on infant mortality.

Methods 
This study performs a fixed-effects panel data analysis of Italian Regions and Autonomous provinces between the years 2001 and 2017, to investigate the effects of health sector-FD on availability, accessibility, and utilisation of healthcare services in Italy.

Results 
FD decreases availability of staff and hospital beds, decreases utilisation of care, measured by hospitalisation rates, and increases interregional patients’ mobility for healthcare purposes, a finding suggesting increased disparities in access to healthcare. These effects seem to be stronger for public – rather than private – services, and are more prominent in poorer areas.

Conclusion 
This evidence suggest that FD has created a fragmented and unequal healthcare system, in which levels of availability, utilisation of, and accessibility to resources – as well as the extent of public sector’s retrenchment – coincide with the wealth of the area.

Highlights

 

Commentaries Published on this Paper 

 

  •  Health System Decentralization: Creating as Many Problems Than It Solves?; Comment on “The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis”

        Abstract | PDF

 

  • Making Sense of the Complexity of Decentralised Governance; Comment on “The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis”

        Abstract | PDF

 

  • Challenges in Assessment of Health Systems Decentralization: The Role of Path Dependence and Choice of Indicators; Comment on “The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis”

        Abstract | PDF

 

Authors' Response to the Commentaries

 

  • The Dangers of Fiscal Decentralisation in Healthcare: A Response to the Recent Commentaries

        Abstract | PDF

 

Keywords

References

  1. Rotulo A, Epstein M, Kondilis E. Fiscal federalism vs fiscal decentralization in healthcare: a conceptual framework. Hippokratia. 2020;24(3):107-113.
  2. Abimbola S, Baatiema L, Bigdeli M. The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence. Health Policy Plan. 2019;34(8):605-617. doi:1093/heapol/czz055
  3. Dwicaksono A, Fox AM. Does decentralization improve health system performance and outcomes in low- and middle-income countries? a systematic review of evidence from quantitative studies. Milbank Q. 2018;96(2):323-368. doi:1111/1468-0009.12327
  4. Cobos Muñoz D, Merino Amador P, Monzon Llamas L, Martinez Hernandez D, Santos Sancho JM. Decentralization of health systems in low and middle income countries: a systematic review. Int J Public Health. 2017;62(2):219-229. doi:1007/s00038-016-0872-2
  5. Weingast BR. Second generation fiscal federalism: implications for decentralized democratic governance and economic development. SSRN Electronic Journal. 2006. doi:2139/ssrn.1153440
  6. Costa Font J, Greer SL. Federalism and Decentralization in European Health and Social Care. Springer; 2016:13-39.
  7. Prud'homme R. The dangers of decentralization. World Bank Res Obs. 1995;10(2):201-220.
  8. Oates WE. The Political Economy of Fiscal Federalism. Lexington: Lexington Books; 1977:5-18. https://books.google.it/books/about/The_Political_economy_of_fiscal_federali.html?id=UQmzAAAAIAAJ&redir_esc=y.
  9. Ferraresi M, Gucciardi G, Rizzo L. Savings from public procurement centralization in the healthcare system. Eur J Polit Econ. 2021;66:101963. doi:1016/j.ejpoleco.2020.101963
  10. Jiménez-Rubio D. The impact of decentralization of health services on health outcomes: evidence from Canada. Appl Econ. 2011;43(26):3907-3917. doi:1080/00036841003742579
  11. Uchimura H, Jütting JP. Fiscal decentralization, Chinese style: good for health outcomes? World Dev. 2009;37(12):1926-1934. doi:1016/j.worlddev.2009.06.007
  12. Jin Y, Sun R. Does fiscal decentralization improve healthcare outcomes? empirical evidence from China. Public Finance and Management. 2011;11(3):234-261.
  13. Brock G, Jin Y, Zeng T. Fiscal decentralization and China's regional infant mortality. J Policy Model. 2015;37(2):175-188. doi:1016/j.jpolmod.2015.03.001
  14. Soto VE, Farfan MI, Lorant V. Fiscal decentralisation and infant mortality rate: the Colombian case. Soc Sci Med. 2012;74(9):1426-1434. doi:1016/j.socscimed.2011.12.051
  15. Asfaw A, Frohberg K, James KS, Jütting J. Fiscal decentralization and infant mortality: empirical evidence from rural India. J Dev Areas. 2007;41(1):17-35. doi:1353/jda.2008.0026
  16. Cavalieri M, Ferrante L. Does fiscal decentralization improve health outcomes? evidence from infant mortality in Italy. Soc Sci Med. 2016;164:74-88. doi:1016/j.socscimed.2016.07.017
  17. Akpan EO. Fiscal decentralization and social outcomes in Nigeria. Eur J Bus Manag. 2011;3(4):167-183.
  18. Cantarero D, Pascual M. Analysing the impact of fiscal decentralization on health outcomes: empirical evidence from Spain. Appl Econ Lett. 2008;15(2):109-111. doi:1080/13504850600770913
  19. Gu XY, Tang SL, Cao SH. The financing and organization of health services in poor rural China: a case study in Donglan County. Int J Health Plann Manage. 1995;10(4):265-282. doi:1002/hpm.4740100404
  20. Tang S, Bloom G. Decentralizing rural health services: a case study in China. Int J Health Plann Manage. 2000;15(3):189-200. doi:1002/1099-1751(200007/09)15:3<189::aid-hpm590>3.0.co;2-q
  21. Huang J, Chen L, Li J, Groot W. Expenditure decentralization and citizen satisfaction with healthcare: evidence from Urban China. Soc Indic Res. 2017;133(1):333-344. doi:1007/s11205-016-1361-y
  22. Akin J, Hutchinson P, Strumpf K. Decentralisation and government provision of public goods: the public health sector in Uganda. J Dev Stud. 2005;41(8):1417-1443. doi:1080/00220380500187075
  23. Maharani A, Tampubolon G. Has decentralisation affected child immunisation status in Indonesia? Glob Health Action. 2014;7:24913. doi:3402/gha.v7.24913
  24. Sanogo T. Does fiscal decentralization enhance citizens’ access to public services and reduce poverty? evidence from Côte d’Ivoire municipalities in a conflict setting. World Dev. 2019;113:204-221. doi:1016/j.worlddev.2018.09.008
  25. Hodge A, Firth S, Jimenez-Soto E, Trisnantoro L. Linkages between decentralisation and inequalities in neonatal health: evidence from Indonesia. J Dev Stud. 2015;51(12):1634-1652. doi:1080/00220388.2015.1081172
  26. Montero-Granados R, de Dios Jiménez J, Martín J. Decentralisation and convergence in health among the provinces of Spain (1980-2001). Soc Sci Med. 2007;64(6):1253-1264. doi:1016/j.socscimed.2006.10.016
  27. Costa Font J, Gil J. Exploring the pathways of inequality in health, health care access and financing in decentralized Spain. J Eur Soc Policy. 2009;19(5):446-458. doi:1177/0958928709344289
  28. Rocco P, Rich JAJ, Klasa K, Dubin KA, Béland D. Who counts where? COVID-19 surveillance in federal countries. J Health Polit Policy Law. 2021;46(6):959-987. doi:1215/03616878-9349114
  29. Costa Font J, Levaggi R, Turati G. Resilient managed competition during pandemics: lessons from the Italian experience during COVID-19. Health Econ Policy Law. 2020:1-8. doi:1017/s1744133120000353
  30. Ji Y, Ma Z, Peppelenbosch MP, Pan Q. Potential association between COVID-19 mortality and health-care resource availability. Lancet Glob Health. 2020;8(4):e480. doi:1016/s2214-109x(20)30068-1
  31. Ferre F, de Belvis AG, Valerio L, et al. Italy: health system review. Health Syst Transit. 2014;16(4):1-168.
  32. Giorgetti R. Legislazione e organizzazione del servizio sanitario. Maggioli Editore; 2019.
  33. President of the Italian Republic. Legislative Decree 56/2000. 56/2000 2000.
  34. President of the Italian Republic. Constitutional Reform 3/2001. 2001.
  35. Brenna E. Quasi-market and cost-containment in Beveridge systems: the Lombardy model of Italy. Health Policy. 2011;103(2-3):209-218. doi:1016/j.healthpol.2011.10.003
  36. Torbica A, Fattore G. The "Essential Levels of Care" in Italy: when being explicit serves the devolution of powers. Eur J Health Econ. 2005;6(Suppl 1):46-52. doi:1007/s10198-005-0318-x
  37. Council of Regions and Autonomous Provinces. Accordo Interregionale per la Compensazione della Mobilità Sanitaria - Inter-regional Agreement for Reimbursing Healthcare Mobility. 2020. https://www.regioni.it.
  38. Cavalieri M, Ferrante L. Convergence, decentralization and spatial effects: an analysis of Italian regional health outcomes. Health Policy. 2020;124(2):164-173. doi:1016/j.healthpol.2019.12.001
  39. Di Novi C, Piacenza M, Robone S, Turati G. Does fiscal decentralization affect regional disparities in health? quasi-experimental evidence from Italy. Reg Sci Urban Econ. 2019;78:103465. doi:1016/j.regsciurbeco.2019.103465
  40. President of the Italian Republic. Presidential Decree concerning the Special Statute of Trentin and its provinces. 670 Trento Provincial Council; 1972.
  41. Ministry of Finances. Territorial Public Accounts - Conti Pubblici Territoriali. 2019. https://www.agenziacoesione.gov.it/sistema-conti-pubblici-territoriali/?lang=en.
  42. Saurman E. Improving access: modifying Penchansky and Thomas's theory of access. J Health Serv Res Policy. 2016;21(1):36-39. doi:1177/1355819615600001
  43. Donabedian A. Aspects of Medical Care Administration: Specifying Requirements for Health Care. Harvard University Press; 1973.
  44. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19(2):127-140. doi:1097/00005650-198102000-00001
  45. Tanahashi T. Health service coverage and its evaluation. Bull World Health Organ. 1978;56(2):295-303.
  46. Joseph AE, Phillips DR. Accessibility and Utilization: Geographical Perspectives on Health Care Delivery. London: Harper & Row; 1984.
  47. ISTAT ISB. Health For All - ISTAT. 2019. https://www.istat.it/it/archivio/14562.
  48. Mathauer I, Saksena P, Kutzin J. Pooling arrangements in health financing systems: a proposed classification. Int J Equity Health. 2019;18(1):198. doi:1186/s12939-019-1088-x
  49. Brenna E, Spandonaro F. Regional incentives and patient cross-border mobility: evidence from the Italian experience. Int J Health Policy Manag. 2015;4(6):363-372. doi:15171/ijhpm.2015.65
  50. Toth F. How health care regionalisation in Italy is widening the North-South gap. Health Econ Policy Law. 2014;9(3):231-249. doi:1017/s1744133114000012
  51. Tiebout CM. A pure theory of local expenditures. J Polit Econ. 1956;64(5):416-424.
  52. Neri S. Interregional patient mobility in the Italian NHS: a case of badly-managed decentralization comment on "Regional incentives and patient cross-border mobility: evidence from the Italian experience.” Int J Health Policy Manag. 2015;4(12):857-859. doi:15171/ijhpm.2015.154
  53. Hospital Discharge Rates (Indicator). OECD; 2020. doi:10.1787/5880c955-en
  54. Levin A, Lin CF, James Chu CS. Unit root tests in panel data: asymptotic and finite-sample properties. J Econom. 2002;108(1):1-24. doi:1016/s0304-4076(01)00098-7
  55. Stock J, Watson MW. Introduction to Econometrics. New York: Prentice Hall; 2017.
  56. Hill RC, Griffiths WE, Lim GC. Principles of Econometrics. John Wiley & Sons; 2011.
  57. Breitung J, Das S. Panel unit root tests under cross-sectional dependence. Stat Neerl. 2005;59(4):414-433. doi:1111/j.1467-9574.2005.00299.x
  58. Hausman JA. Specification tests in econometrics. Econometrica. 1978;46(6):1251-1271. doi:2307/1913827
  59. Friedman M. The lag in effect of monetary policy. J Polit Econ. 1961;69(5):447-466.
  60. Baum CF, Schaffer ME, Stillman S. Instrumental variables and GMM: estimation and testing. Stata J. 2003;3(1):1-31. doi:1177/1536867x0300300101
  61. Arcà E, Principe F, Van Doorslaer E. Death by austerity? the impact of cost containment on avoidable mortality in Italy. Health Econ. 2020;29(12):1500-1516. doi:1002/hec.4147
  62. Tanzi V. The Future of Fiscal Federalism. WZB Berlin Social Science Center; 2008. https://EconPapers.repec.org/RePEc:zbw:wzbmpg:spii200803.
  63. France G. Cost containment in a public-private health care system: the case of Italy. Public Budg Finance. 1991;11(4):63-74. doi:1111/1540-5850.00920
  64. McPake B, Normand C. Cost of delivering health services. In: Health Economics: An International Perspective. 2nd ed. Routledge; 2020:35-39.
  65. Ciani O, Tarricone R, Torbica A. Diffusion and use of health technology assessment in policy making: what lessons for decentralised healthcare systems? Health Policy. 2012;108(2-3):194-202. doi:1016/j.healthpol.2012.09.017
  66. Bobini M, Ricci A. Oasi Report 2019 - Observatory of health enterprises and on the National Health Service. Cercas Bocconi; 2019.
  67. Ciarini A, Neri S. ‘Intended’ and ‘unintended’ consequences of the privatisation of health and social care systems in Italy in light of the pandemic. Transfer. 2021;27(3):303-317. doi:1177/10242589211028458
  68. Vicarelli G, Pavolini E. Health workforce governance in Italy. Health Policy. 2015;119(12):1606-1612. doi:1016/j.healthpol.2015.09.004
  69. Pavolini E, Vicarelli G. Is decentralization good for your health? transformations in the Italian NHS. Curr Sociol. 2012;60(4):472-488. doi:1177/0011392112438332
  70. Lago FP, Moscoso NS, Elorza ME, Ripari NV. [Decentralization and equity: public health expenditure in the municipalities of the Province of Buenos Aires]. Salud Colect. 2012;8(3):263-274. doi:1590/s1851-82652012000400004
  71. Benos A, Kondilis E, Pantoularis I, Makridou E, Rotulo A, Seretis S. Critical Assessment of Preparedness and Policy Responses to SARS-CoV2 Pandemic: International and Greek Experience. CEHP - Centre for Research and Education in Public Health, Health Policy and Primary Health Care; 2020.
  72. A Strategic Framework for Emergency Preparedness. 2017. https://www.who.int/ihr/publications/9789241511827/en/.
  73. Carinci F. Covid-19: preparedness, decentralisation, and the hunt for patient zero. BMJ. 2020;368:bmj.m799. doi:1136/bmj.m799
  74. Fisman R, Gatti R. Decentralization and corruption: evidence across countries. J Public Econ. 2002;83(3):325-345. doi:1016/s0047-2727(00)00158-4
International Journal of Health Policy and Management
Volume 11, Issue 11
November 2022
Pages 2440-2450

Files

History

  • Receive Date: 25 January 2021
  • Revise Date: 24 October 2021
  • Accept Date: 27 November 2021
  • First Publish Date: 28 November 2021

Share

How to cite

Statistics