The effects of Fiscal Decentralisation on access to care and healthcare disparities: International evidence and the Italian experience

引言财政分权包括将集中和支出的责任从中央政府转移到一个国家内部较低的治理级别。卫生部门财政分权(FDH)作为实现国家成本效益的一种选择，一直是卫生政策辩论的核心。方法本研究采用了系统的文献综述、专题政策分析和面板数据分析相结合的方法。其目的是评估外佣在不同国家背景下的影响；探索意大利的外佣政策进程，并评估其对获得护理的多个方面--即可获得性、可获得性和医疗服务的利用--以及意大利地区医疗保健不平等的影响。结果和讨论总体而言，外籍家庭佣工的实施对护理质量和提供以及卫生保健和获得机会方面先前存在的差距产生了不利影响。在意大利，外佣政策逐渐用地方专项税取代了中央收入池，为地区医疗服务提供资金。这种转变与供应面的削减和地方层面医疗服务利用率的降低有关。此外，外佣减少了获得当地医疗服务的机会，并扩大了区域医疗旅游，对居住在较贫穷地区的患者的影响更大。结果表明，在意大利，外籍家庭佣工以减少地方一级获得护理的机会为代价，促进了国家成本控制战略。这一影响使该国北部和南部地区之间现有的不平等现象永久化。

IntroductionFiscal decentralisation consists in the transfer of pooling and spending responsibilities from the central government to lower levels of governance within a country. Health sector fiscal decentralisation (FDH) has been central in the health policy debate as an option to achieve national cost-efficiency. However, its effects on access to care and healthcare disparities remain largely unexplored.MethodsThis research employs a mixed methods approach consisting of a systematic literature review, a thematic policy analysis, and a panel data analysis. The aim is to evaluate the effect of FDH in diverse country contexts; to explore FDH policy process in Italy and to estimate its impact on multiple dimensions of access to care - i.e. availability, accessibility, and utilisation of care - and on healthcare inequities in Italian regions. Results and discussionOverall, the implementation of FDH has a detrimental effect on the quality and provision of care, as well as on pre-existing disparities in health and access. In Italy, FDH policies gradually replaced central pooling of revenues with local earmarked taxes to fund regional healthcare services. The shift is correlated to cuts on the supply side and to reduced utilisation of care at local levels. Additionally, FDH decreased accessibility to local healthcare services and expanded regional medical tourism, the effect being stronger for patients residing in poorer areas. Results suggest that in Italy FDH has facilitated national cost control strategies at the expenses of reduced access to care at local levels. The effect perpetuates existing inequities between northern and southern regions of the country.