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

Document Type : Original Article


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


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.

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.

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.

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.



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



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Volume 11, Issue 11
November 2022
Pages 2440-2450
  • Receive Date: 25 January 2021
  • Revise Date: 24 October 2021
  • Accept Date: 27 November 2021
  • First Publish Date: 28 November 2021