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”

Document Type : Commentary

Author

Department of Applied Economics, University of Granada, Granada, Spain

Abstract

This comment draws on the study by Rotulo et al about the effects of fiscal decentralization on access, utilization and availability of healthcare resources across Italian regions. We start by discussing the recent trends in health system decentralization worldwide, and then reflect on the rationale and main benefits and the key complexities and challenges of this much debated reform. We address these issues with reference to the recent experience of Italy as well as that of other comparable highly decentralized countries, most notably Spain, paying particular attention to their similarities and contrasts. We conclude that decentralization of health services poses complex challenges and trade-offs which may require careful design of equalisation mechanisms, framework regulation and efficient coordination mechanisms by central and sub central governments.

Keywords


  1. Dougherty S, Lorenzoni L, Marino A, Murtin F. The impact of decentralisation on the performance of health care systems: a non-linear relationship. Eur J Health Econ. 2022;23(4):705-715. doi:1007/s10198-021-01390-1
  2. Organisation for Economic Co-operation and Development (OECD). Making Decentralisation Work: A Handbook for Policy-Makers. Paris: OECD Publishing; 2019.
  3. Waitzberg R, Hernández-Quevedo C, Bernal-Delgado E, et al. Early health system responses to the COVID-19 pandemic in Mediterranean countries: a tale of successes and challenges. Health Policy. 2022;126(5):465-475. doi:1016/j.healthpol.2021.10.007
  4. Jiménez-Rubio D, García-Gómez P. Decentralization of health care systems and health outcomes: evidence from a natural experiment. Soc Sci Med. 2017;188:69-81. doi:1016/j.socscimed.2017.06.041
  5. 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
  6. Weingast BR. Second generation fiscal federalism: the implications of fiscal incentives. J Urban Econ. 2009;65(3):279-293. doi:1016/j.jue.2008.12.005
  7. Rotulo A, Paraskevopoulou C, Kondilis E. The effects of health sector fiscal decentralisation on availability, accessibility, and utilisation of healthcare services: a panel data analysis. Int J Health Policy Manag. 2021. doi:34172/ijhpm.2021.163
  8. Mitze T, Kosfeld R, Rode J, Wälde K. Face Masks Considerably Reduce COVID-19 Cases in Germany: A Synthetic Control Method Approach. IZA Discussion Paper Series No. 13319. Bonn, Germany: IZA Institute of Labour Economics; 2020.
  9. Gallo P, Gené-Badia J. Cuts drive health system reforms in Spain. Health Policy. 2013;113(1-2):1-7. doi:1016/j.healthpol.2013.06.016
  10. Fernández-Pérez Á, Jiménez-Rubio D, Robone S. The Effect of Freedom of Choice on Health System Responsiveness. Evidence from Spain. Working Papers 19/21. Health, Econometrics and Data Group (HEDG; 2019.
  11. Redacción Médica. El Gobierno se fija en Navarra para elegir qué fármacos antitabaco financia. https://www.redaccionmedica.com/secciones/ministerio-sanidad/el-gobierno-se-fija-en-navarra-para-elegir-que-farmacos-antitabaco-financia-9971. Published May 8, 2019.  
  12. Costa-Font J, Turati G. Regional healthcare decentralization in unitary states: equal spending, equal satisfaction? Reg Stud. 2018;52(7):974-985. doi:1080/00343404.2017.1361527
  13. Blázquez Fernández C, Cantarero Prieto D, Pascual Sáez M. Patient cross-border mobility: new findings and implications in Spanish regions. Econ Sociol. 2017;10(1):11-21. doi:14254/2071-789x.2017/10-1/1
  14. Repullo Labrador JR. Gasto sanitario y descentralización: saldrá a cuenta haber transferido el INSALUD? Presupuesto y Gasto Público. 2007;49:47-66.
  15. Heitmueller A, Roemheld L. COVID-19 and the False Dichotomy between Centralised and Decentralised Healthcare Systems. The BMJ Opinion. https://blogs.bmj.com/bmj/2020/08/05/covid-19-and-the-false-dichotomy-between-centralised-and-decentralised-healthcare-systems/. Published August 5, 2020.
  • Receive Date: 02 June 2022
  • Revise Date: 20 September 2022
  • Accept Date: 28 September 2022
  • First Publish Date: 02 October 2022