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2
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www.else ie .p / psp
O iginal
a icle
E ficiency
and
equi y
consequences
o
decen aliza ion
in
heal h:
an
economic
pe spec i e
Joana
Al esa,∗,
Susana
Pe al ab,
Julian
Pe elmana
aEscola
Nacional
de
Saúde
Pública,
Uni e sidade
No a
de
Lisboa,
Lisboa,
Po ugal
bNo a
School
o
Business
and
Economics,
Uni e sidade
No a
de
Lisboa,
Lisboa,
Po ugal
a
i
c
l
e
i
n
o
A icle
his o y:
Recei ed
17
Sep embe
2012
Accep ed
21
Janua y
2013
A ailable
online
10
July
2013
Keywo ds:
Decen aliza ion
E ficiency
Equi y
Heal h
economics
Incen i es
a
b
s
a
c
O e
he
ecen
yea s,
decen aliza ion
has
been
adop ed
in
many
heal h
sys ems.
The
ques ion
howe e
emains
o
whe he
local
ac o s
do
be e
han
he
cen al
go e nmen .
We
summa ize
he
main
insigh s
om
economic
heo y
on
he
impac
o
decen aliza-
ion
and
i s
empi ical
alida ion.
Theo y
sugges s
ha
he
decision
o
decen alize
esul s
om
a
ade-o
be ween
i s
ad an ages
(like
i s
capaci y
o
ca e
o
local
as es)
and
cos s
(like
in e - egional
spillo e s).
Empi ical
con ibu ions
poin
ha
decen aliza ion
esul s
in
be e
heal h
ou comes
and
highe
expendi u es,
esul ing
in
ambiguous
consequences
on
e ficiency;
equi y
consequences
a e
con o e sial
and
add ess
he
ele ance
o
edis ibu ion
mechanisms.
©
2012
Escola
Nacional
de
Saúde
Pública.
Published
by
Else ie
España,
S.L.
All
igh s
ese ed.
Consequências
em
eficiência
e
equidade
da
descen alizac¸ão
na
saúde:
uma
pe spe i a
económica
Pala as-cha e:
Descen alizac¸ão
Eficiência
Equidade
Economia
da
saúde
Incen i os
e
s
u
m
o
Apesa
de
mui os
sis emas
de
saúde
e em
op ado
ecen emen e
pela
descen alizac¸ão,
fica
po
escla ece
se
os
go e nos
locais
êm
um
melho
desempenho
do
que
os
cen-
ais.
Es e
a igo
suma iza
os
p incipais
esul ados
da
eo ia
económica
sob e
o
impac o
da
descen alizac¸ão
e
a
sua
alidade
empí ica.
A
decisão
de
descen aliza
esul a
duma
a bi-
agem
en e
as
an agens,
como
a
adap ac¸ão
às
p e e ências,
e
os
incon enien es,
como
as
ex e nalidades
in e - egionais.
Os
es udos
empí icos
suge em
que
a
descen alizac¸ão
pe -
mi e
ganhos
em
saúde
mas
ambém
despesas
maio es,
com
consequências
ambíguas
em
e mos
de
eficiência,
e
que
as
consequências
pa a
a
equidade,
sendo
con o e sas,
indicam
a
ele ância
dos
mecanismos
de
edis ibuic¸ão.
©
2012
Escola
Nacional
de
Saúde
Pública.
Publicado
po
Else ie
España,
S.L.
Todos
os
di ei os
ese ados.
∗Co esponding
au ho .
E-mail
add ess:
joana.al [email protected]
(J.
Al es).
0870-9025/$
–
see
on
ma e
©
2012
Escola
Nacional
de
Saúde
Pública.
Published
by
Else ie
España,
S.L.
All
igh s
ese ed.
h p://dx.doi.o g/10.1016/j. psp.2013.01.002
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(1):74–83
75
In oduc ion
O e
he
ecen
yea s,
decen aliza ion
has
been
one
o
he
main
e o ms
adop ed
in
many
heal h
sys ems.
S ong
deci-
sion
powe
o
sub-cen al
go e nmen s
al eady
exis ed
in
Scandina ian
coun ies
and
in
ede al
s a es
like
Canada,
Swi ze land
and
Aus alia1;
he
mos
ecen
de olu ion
p o-
cesses
ha e
been
obse ed
in
NHS
sys ems,
namely
in
Spain
and
I aly
( owa d
egions),
and
he
UK
( owa d
Wales,
Sco -
land,
No he n
I eland).
In
a
ew
wo ds,
mo e
delega ion
o
local
au ho i ies
was
expec ed
o
imp o e
se ices
h ough
a
combina ion
o
be e
knowledge
o
local
needs,
p e e -
ences
and
p o ide s’
cha ac e is ics,
highe
accoun abili y
o
policy-make s
and
e ficiency-enhancing
compe i ion
among
ju isdic ions.
These
expec ed
benefi s
a e
howe e
a
om
ob ious
and
he
majo
ques ion
o
policy-make s
and
esea che s
emains,
ha
is,
whe he
local
ac o s
eally
do
be e
han
he
cen al
go e nmen .
Pu
di e en ly,
he
issue
is
whe he
decen aliza ion
allows
o
he
p o ision
o
be e
and
equi-
able
heal h
se ices
o
all
ci izens
a
an
accep able
cos .
Oa es2was
he
fi s
one
o
sugges
ha
he
decision
o
decen-
alize
esul s
om
a
ade-o
be ween
i s
ad an ages
and
cos s.
Whe he
he
benefi s
ac ually
ou weigh
he
cos s
–
he
e ficiency
issue
–
is
ul ima ely
an
empi ical
ques ion.
The
li e a u e
has
mainly
ocused
on
o e all
e ficiency
by
es i-
ma ing
he
impac
o
decen aliza ion
on
economic
g ow h.3,4
Ano he
al e na i e
is
o
measu e
he
impac
o
decen aliza-
ion
on
sec o al
policies.5Decen aliza ion
o
heal h
policies
is
ela i ely
ecen ;
he
li e a u e
is
s ill
sca ce
and
o en
p o-
ides
con adic o y
esul s.
We
summa ize
he
main
insigh s
om
economic
heo y
on
he
impac
o
decen aliza ion
o
heal h
policies,
and
we
e iew
empi ical
s udies
ha
ha e
es ed
some
o
hese
heo e ical
assump ions.
Ins i u ional
con ex
Decen aliza ion
in
heal h
ca e
can
adop
many
di e en
o ms.
Following
he
ypology
p oposed
by
V angbaek,6ou
main
in e es
he e
is
in
de olu ion
o
poli ical
decen aliza ion,
h ough
which
powe
is
“decen alized
o
lowe -le el
poli ical
au ho i ies
such
as
egions
o
municipali ies”.
O he
o ms
o
decen aliza ion
a e
also
possible
which
a e
beyond
he
scope
o
he
p esen
pape .
De-concen a ion
and
bu eauc a-
iza ion
in ol e
ans e s
be ween
adminis a i e
le els
and
om
poli ical
o
adminis a i e
le el,
espec i ely
( hink
o
example
in
he
Po uguese
con ex ,
o
ans e
o
compe ences
o
Regional
Heal h
Au ho i ies).
Decen aliza ion
also
e e s
o
delega ion,
which
in ol es
ans e ing
powe
o
mo e
o
less
au onomous
public
o ganiza ion
managemen
(like
pub-
lic
en e p ises,
o
example
he
“hospi als
S.A”
in
Po ugal,
Founda ion
T us s
in
he
UK
o
public
insu ance
companies
in
Bisma ckian- ype
heal h
sys ems).
P i a iza ion
i sel
can
be
conside ed
as
a
o m
o
decen aliza ion.
Ou
ocus
he e
is
hus
on
he
ans e
o
poli ical
au ho i y
in
he
heal h
a ea
om
highe
o
lowe
le els
o
go e nmen
o
om
na ional
o
sub-na ional
le els.7Regional,
p o incial
o
municipal
elec ed
go e nmen s
may
hus
be
esponsible
o
planning,
o ganizing,
deli e ing
and
financing
heal h
se ices.
Mul iple
a angemen s
a e
howe e
possible
and
de olu ion
has
aken
many
di e en
o ms
ac oss
OECD
coun ies
( o
a
comple e
mapping
o
decen aliza ion
expe iences
in
Eu ope,
see
Bankauskai e
e
al.8).
The
size
o
decen alized
en i ies
is
highly
a iable,
om
small
coun ies
in
Sweden
(a e age
popula ion
31,000)
o
la ge
au onomous
egions
in
Spain
(a e -
age
popula ion
2,444,000).
The
ex en
o
compe ences
also
a ies.
The
cen al
s a e
may
keep
esponsibili ies
in
se e al
domains,
o
ins ance
he
Canadian
Fede al
s a e
defines
poli-
cies
ega ding
heal h
p e en ion
and
p omo ion,
he
Swiss
Con ede a ion
defines
he
basic
heal h
benefi
package,
and
gene ally
all
cen al
s a es
impose
a
se ies
o
mo e
o
less
s ingen
egula ions
on
quali y,
supply,
co e age,
p icing
ules
o
budge
alloca ion.
A
key
issue
which
di e en ia es
decen aliza ion
expe iences
ela es
o
he
unding
o
heal h
expendi u es
and
financial
au onomy.
Decen alized
go e n-
men s
may
ha e
he
powe
o
aise
axes,
o
ecei e
ans e s
depending
on
hei
con ibu ion
o
fiscal
e enues.
They
may
hen
be
ee
o
se
he
budge
alloca ed
o
heal h
and
i s
dis ibu ion
among
heal h
sec o s.
By
con as ,
sub-cen al
go e nmen
le els
may
be
financed
by
ans e s
based
on
isk-equaliza ion
schemes
and
benefi
om
low
au onomy
in
defining
ax
a es.
In
he
la e
case,
decen alized
go -
e nmen s
may
hus
ha e
he
poli ical
powe
o
decide
abou
alloca ion
o
esou ces
bu
do
no
con ol
he
amoun
o
a ailable
esou ces
o
heal h.
Hence
he
expendi u e
side
is
decen alized,
bu
e enue
is
no .
Fig.
1,
ex ac ed
om
Jouma d
e
al.9,
nicely
desc ibes
he
deg ee
o
decen aliza ion
in
heal h
in
OECD
coun ies
(whe e
a
0
sco e
implies
ha
cen al
go e nmen
akes
mos
o
key
decisions
while
a
6
sco e
implies
esidual
compe ences
o
he
cen al
go e nmen ).
Coun ies
ha e
he e ogeneous
sub-cen al
go e nmen s,
wi h
di e en
size,
au onomy
and
esponsibili ies
alloca ed.
The
c i e ia
o
define
his
sco e
ha e
been
es ablished
by
Pa is
e
al.10,
using
a
su ey.
They
include
in
pa icula
he
sub-cen al
go e nmen s’
au ho i y
on
se -
ing
ax
bases
and
a es,
he
budge
alloca ion
o
heal h
and
i s
dis ibu ion
be ween
heal h
sec o s,
he
financing
o
di e en
heal h
se ices
and
p ac i ione s
and
he
se ing
o
public
heal h
objec i es.
Spain,
Canada,
Finland,
Sweden
and
Swi ze land
ha e
highe
au onomy
o
sub-cen al
go e n-
men s
while
Po ugal
is
among
he
coun ies
wi h
he
lowes
heal h
decen aliza ion.
No e
ha
he
decen aliza ion
ques ion,
he
way
we
pose
i
(de olu ion
o
poli ical
decen aliza ion),
is
mo e
common
in
NHS- ype
heal h
sys ems.
These
sys ems
ha e
been
usually
cha ac e ized
by
highly
cen alized
decision-making,
wi h
one
single
insu e /paye
and
p o ide
( he
cen al
s a e),
and
li -
le
au onomy
gi en
o
p o ide s.
By
con as ,
heal h
sys ems
based
on
social
insu ance
schemes
ha e
been
usually
cha -
ac e ized,
o
a ious
ex en s,
by
mul iple
insu ance
schemes
and
some
deg ee
o
publicly
subsidized
p i a e
p o ision.
Hence,
ans e ing
powe
o
local
ins i u ions
has
ce ainly
esponded
o
a
demand
o
mo e
au onomy
in
mo e
igid
NHS-
ype
heal h
sys ems.
Spain,
Canada
and
I aly
a e
pa icula ly
ele an
cases
o
unde s and
he
empi ical
li e a u e
because
he
consequences
o
decen aliza ion
in
heal h
ha e
been
mo e
ex ensi ely
analyzed.
The
mos
decen alized
coun y
acco ding
o
76
e
p
o
s
a
ú
d
e
p
ú
b
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i
c
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2
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6
5
4
3
2
1
0
FRA
GRC
IRL
KOR
LUX
NLD
TUR
ISL
BEL
SVK
PRT
HUN
CZE
DEU
POL
MEX
JPN
ITA
DNK
NZL
AUS
GBR
NOR
AUT
SWE
CHE
FIN
CAN
ESP
Fig.
1
–
Decen aliza ion
sco e
o
OECD
coun ies
(ex ac ed
om
Jouma d
e
al.9).
Jouma d
e
al.9is
Spain.
The
cen al
go e nmen
p o ides
he
gene al
amewo k
and
coo dina es
he
heal h
sys em
while
Au onomous
Communi ies
(AC)
p o ide
heal h
ca e
se ices
and
a e
esponsible
o
heal h
planning,
o ganiza ion
and
managemen .11 Funds
a e
cen ally
collec ed
and
alloca ed
o
egions
by
means
o
a
block
cen al
g an
ollowing
an
unadjus ed
capi a ion
o mula.11 Only
Na a a
and
he
Basque
Coun y
benefi
om
fiscal
au ho i y.
By
con as ,
he
Canadian
Con ede a ion,
composed
o
10
p o inces
and
3
e i o ies,
has
been
decen alized
since
he
19 h
cen u y.12 Heal h
unding,
adminis a ion
and
deli e ing
a e
compe ences
o
p o inces,
which
also
define
physician
financing
ules
and
hospi al
global
budge s.
Howe e
heal h
p omo ion,
p e en ion
and
p o ision
o
specific
g oups
a e
Fede al
compe encies.
P o inces
a e
esponsible
o
und-
ing
heal h
ca e
expendi u es,
based
on
p o incial
axes
and
ans e s
om
he
cen al
go e nmen .
T ans e s
depend
hemsel es
on
axes
collec ed
a
p o incial
le el;
an
equal-
iza ion
p og am
was
howe e
implemen ed
o
a oid
s ong
di e ences
in
ans e s
ela ed
o
disc epancies
in
p o inces’
e enue-gene a ing
po en ial.13
Finally,
he
20
I alian
egions
also
con ol
heal h
ca e
p o ision,
al hough
gene al
objec i es
(like
he
de ailed
lis
o
se ices
o
be
p o ided)
and
main
p inciples
o
he
heal h
sys em
a e
defined
a
he
cen al
le el.
Regions
can
de elop
egional
heal h
plans,
alloca e
esou ces
and
collec
e enues
eely,
like
se ing
use
cha ges
o
d ugs
p esc ip ions
o
eimbu se
a es
o
d ugs
and
se ices
no
co e ed
a
na ional
le el.
Regional
au ho i ies
also
enjoy
financial
au onomy
in
axa ion;
in
p ac ice,
egional
heal h
expendi u es
a e
financed
a
36.7%
by
egional
axes.14 Addi ionally,
egional
heal h
expendi u es
a e
financed
by
ans e s
om
he
cen al
s a e
(57.3%
o
expendi u es),
essen ially
om
a
so-called
Na ional
equalizing
und.
This
und
is
based
on
he
idea
ha
all
egions
mus
achie e
a
minimum
le el
o
expendi u es,
so
ha
ans e s
op
up
egions’
own
e enue
in
case
i
is
unable
o
und
his
minimum
le el.
Theo e ical
backg ound
The
deba e
on
he
ela i e
me i s
o
policy
decen aliza ion
da es
back
o
Tiebou ,15 who
pu
o wa d
a
e y
op imis ic
a gumen
o
he
op imali y
o
local
public
good
p o i-
sion,
based
on
an
analogy
be ween
compe i i e
ma ke s
and
compe ing
ju isdic ions.
Oa es,2in
con as ,
sugges s
ha
decen aliza ion
esul s
om
a
ade-o
be ween
i s
ad an ages
and
cos s.
Acco ding
o
Oa es,
he
ad an age
o
decen aliza ion
lies
in
i s
capaci y
o
ca e
o
local
as es,
be
i
because
o
be e
in o ma ion
o
simply
because
he
cen-
al
go e nmen
canno
di e en ia e
public
good
p o ision.
The
cos
o
decen aliza ion
s ems
essen ially
om
he
p es-
ence
o
in e - egional
spillo e s.
Fo
ins ance,
be e
heal h
p e en ion
in
one
municipali y
benefi s
i s
neighbo s.
How-
e e ,
i
heal h
p e en ion
is
decen alized,
each
municipali y
ails
o
ake
in o
accoun
he
benefi
o
i s
in es men
in
o he
municipali ies,
and
is
he e o e
likely
o
in es
sub-op imally,
leading
o
unde -p o ision
and/o
low
quali y
o
heal h
se -
ices.
While
Oa es’
a gumen
ha
a
cen al
go e nmen
is
unable
o
di e en ia e
he
p o ision
o
local
public
goods
acco ding
o
local
p e e ences
has
been
challenged
since,
his
main
in ui ion
ha
he
decision
o
decen alize
es s
on
a
un-
damen al
ade-o
be ween
cos s
and
ad an ages
emains.
One
o
he
main
cos s
o
decen aliza ion
which
has
been
analyzed
in
he
li e a u e
is
he
ailu e
o
exploi
economies
o
scale.16 Fo
ins ance,
collec i e
pu chasing
o
esou ces
(d ugs,
medical
de ices,
equipmen s,
e c.)
o
collec i e
admin-
is a ion
o
heal h
se ices
may
display
dec easing
a e age
cos s
and
be
hus
mo e
e ficien ly
p o ided
a
a
cen alized
le el.
The
in e - egional
spillo e s
a
he
hea
o
Oa es’s
a gu-
men ,
e e ed
he e-abo e,
a e
o
he
ho izon al
ype
( ha
is,
be ween
sub-cen al
go e nmen s
o
he
same
le el).
Ano he
so
o
spillo e s
which
may
c ea e
ine ficiencies
unde
decen-
aliza ion
is
he
e ical
ones
be ween
local
and
cen al
go e nmen s.
These
occu
i
one
go e nmen
le el’s
policy
decisions
ha e
an
impac
in
he
policy
ou comes
o
he
o he
le el.
These
phenomena
a e
highly
plausible
in
he
heal h
ca e
sec o .
I ,
o
example,
sub-cen al
go e nmen s
a e
espon-
sible
o
some
public
heal h
p e en ion
p og ams
and
he
cen al
s a e
deli e s
heal h
ca e,
local
policies
likely
a ec
se ices
use
and
cos s
a
he
cen al
le el.
Unless
sub-cen al
go e nmen s
a e
ewa ded
o
hei
ac ions,
hey
ha e
li le
incen i es
o
p o ide
an
op imal
alue
o
p e en ion,
whose
benefi s
a e
ully
enjoyed
by
he
cen al
s a e.
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(1):74–83
77
Recen ly,
he
li e a u e
has
pu
o wa d
poli ical
economy
a gumen s
in
a o
o
decen aliza ion.
Fo
ins ance,
i
may
be
ha
he
o e s,
who
a e
impe ec ly
in o med
abou
he
economy,
use
he
policies
pu
in
place
by
he
neighbo ing
poli icians
o
impose
discipline
on
hei
own
local
ep e-
sen a i e.
In
such
a
wo ld
o
oppo unis ic
policy
make s,
decen aliza ion
may
be
a
s ong
mechanism
o
p e en
co -
up ion
o
p omo e
p o ision
o
public
se ices.17 Ano he
a gumen
is
ha
decen aliza ion
o ces
local
ju isdic ions
o
compe e
o
mobile
esou ces
( o
ins ance,
labo
o
capi al)
and
pu s
a
downwa d
p essu e
on
axa ion,
hus
p omp ing
a
mo e
e ficien
use
o
sca ce
esou ces
(see
Wilson18 o
a
su -
ey
o
he
ax
compe i ion
li e a u e).
Besley
and
Sma 19 show
ha
his
need
no
be
he
case,
since
highe
discipline
o
local
poli icians
comes
a
he
cos
o
a
wo se
selec ion.
Indeed,
i
is
only
when
an
oppo unis ic
poli ician
misbeha es
ha
he
o e s
a e
gi en
he
chance
o
ous
he
om
powe
and
eplace
he
wi h
a
po en ially
bene olen
poli ician.
Poli ical
accoun -
abili y
esul s
om
a
ade-o
be ween
hese
wo
mechanisms
(discipline
and
selec ion),
and
u he
decen aliza ion
has
opposi e
e ec s
in
bo h.
Wha
can
be
said
abou
he
likelihood
o
local
go e n-
men s
being
cap u ed
by
special
in e es s?
Ba dhan
and
Mookhe jee20 show
ha
he e
is
no
heo e ical
eason
o
sup-
pose
ha
local
go e nmen s
a e
mo e
p one
o
his
han
cen al
ones.
They
pu
o wa d
a
heo e ical
model
o
p oba-
bilis ic
o ing
whe e
cap u e
by
special
in e es s
esul s
om
a
combina ion
o
o e
awa eness,
in e es
g oup
cohesi eness,
elec o al
unce ain y
and
compe i ion,
dis ic
he e ogenei y
and
he
elec o al
sys em.
Thei
main
conclusion
is
ha
he
ex en
o
cap u e
a
he
local
le el
is
mos
likely
con ex -
specific
and
needs
o
be
assessed
empi ically.
A
ew
au ho s
ha e
looked
a
he
applicabili y
o
hese
a gu-
men s
o
he
specific
case
o
heal h
decen aliza ion.
Le aggi
and
Smi h21 claim
ha
sub-cen al
go e nmen s
a e
be e
in o med
abou
he
cons ain s
o
local
supply
and
abou
a i-
a ions
in
demand.
Va ia ions
in
demand
a e
ob iously
ela ed
fi s
o
di e ences
in
local
needs,
o
ins ance
egions
expe i-
ence
disc epancies
in
he
p e alence
o
diseases,
in
beha io al
and
non-beha io al
isk
ac o s
(including
in
pa icula
age-
ing
o
social
de e minan s),
pe haps
also
in
he
e ec i eness
o
specific
in e en ions.
Hence
p io i ies
a e
likely
o
di e
acco ding
o
bu den
o
disease
o
cos -e ec i eness
c i e ia.
Also
local
p e e ences
shape
a ia ions
in
demand,
leading
o
di e en
p io i ies
and
esou ce
alloca ion
c i e ia.
We
may
hink
ha
some
egions
ha e
a
highe
conce n
o
inequali ies
in
heal h
and
social
de e minan s,
while
o he s
pu
a
g ea e
emphasis
on
p o ide
choice
and
esponsi eness
o
pa ien s’
p e e ences.
These
di e ences
in
needs
and
p e e ences
a e
e y
clea
i
we
compa e
Eu opean
coun ies.
Disc epancies
in
local
supply
a e
ela ed
o
he
a ailabili y
and
densi y
o
physicians,
nu ses,
equipmen s,
bu
also
o
di e ences
in
local
p ices
and
p ac ices.
Cen al
go e nmen s
ha e
ied
o
accoun
o
hese
di e ences
in
financing
sub-cen al
go e n-
men s,
h ough
mo e
o
less
sophis ica ed
isk-adjus men
schemes,
bu
may
no
be
able
o
add ess
hese
issues
o
locally
adjus ed
planning
o
o ganiza ion.
Sub-cen al
go e nmen s
may
be
be e
equipped
o
espond
o
local
p e e ences
and
p io i ies,
o
coo dina e
p o ide s’
ac ions
and
o
iden i y
he
sou ces
o
ine ficiency.
Hence,
decen aliza ion
is
expec ed
o
enhance
quali y
and
esponsi eness
o
ca e
while
educing
cos s;
his
heo e ical
iew
is
a
he
o igin
o
mos
decen al-
iza ion
p ocesses.
As
ega ds
he
po en ial
incen i es
ha
a o
e ficiency
and/o
quali y
in
heal h
ca e
p o ision,
bo h
he
ax
compe-
i ion
and
he
ya ds ick
compe i ion
mechanisms
a e
likely
o
a ise
in
heal h
policies,
hus
leading
sub-cen al
go e n-
men s
o
compe e
wi h
each
o he
o
p o ide
high-quali y
se ices
a
low
use
cha ges
o
financed
h ough
lowe
axes.
Fi s ,
be e
and
mo e
e ficien
se ices
con ibu e
o
a ac
mobile
ci izens,
hence
inc ease
sub-cen al
go e nmen s’
economic
ac i i y
and
fiscal
e enues.
Second,
compe i ion
occu s
h ough
ci izens
benchma king
hei
demands
on
he
basis
o
neighbo
sub-cen al
go e nmen s’
pe o mance.22 I
sub-cen al
go e nmen s
a e
poli ically
accoun able,
a
local
poli ician
p o iding
poo e
se ices
han
his
neighbo s’
coun-
e pa s
would
likely
ail
e-elec ion.
In
a
ew
wo ds,
e ficien
p o ision
con ibu es
o
a ac i eness
and
ci izens’
sa is ac-
ion.
I
is
a
well-known
ac
ha
decen aliza ion
may
ham-
pe
edis ibu ion
(see,
C eme
e
al.23 o
a
su ey
o
he
li e a u e),
when
axes
a e
locally
collec ed.
A eas
wi h
high
heal h
needs
a e
in
gene al
he
poo e
ones
( he e
is
la ge
e idence
o
he
ela ionship
be ween
po e y
and
poo
heal h
s a us,
see
Ma mo
Re iew24);
unde
fiscal
decen al-
iza ion,
unde p i ileged
a eas
cap u e
lowe
esou ces
om
axa ion
and
benefi
om
a
lowe
capaci y
o
in es
in
high-
quali y
se ices
and
e ficien
p o ision.
Decen aliza ion
hen
p oduces
di e ences
in
he
quali y
and
a ailabili y
o
se -
ices,
cha ges
and
ou comes.
Inc easing
inequi y
is
one
o
he
majo
h ea s
o
decen aliza ion,
e en
i
good
isk-sha ing
ag eemen s
po en ially
mi iga e
his
e ec .
In
o he
wo ds,
he
iabili y
o
decen aliza ion
depends
on
he
exis ence
o
solida i y
mechanisms
be ween
decen alized
au ho i-
ies.
The
e e se
is
also
possible,
i.e.,
sub-cen al
go e nmen s
only
compe ing
on
high-quali y
se ices,
leading
o
o e -
p o ision
o
se ices
and
high
heal h
expendi u es
( ace
o
he
op).
This
si ua ion
is
mo e
likely
o
occu
when
fiscal
decen aliza ion
is
low
and
sub-cen al
go e nmen s
ace
so
budge
cons ain s.
This
may
he
case,
o
example,
i
he
cen al
go e nmen
sys ema ically
bails
ou
sub-cen al
go -
e nmen s
which
a e
excessi ely
indeb ed
o
i
ans e s
o
sub-cen al
go e nmen s
a e
based
on
pas
expendi u es.
This
b ings
us
o
he
undamen al
ques ion
o
he
und-
ing
o
local
public
goods.
Indeed,
a ious
a angemen s
a e
possible
ega ding
he
deg ee
o
decen aliza ion
o
bo h
he
expendi u e
and
he
e enue
unc ions.25 A
conside able
sha e
o
local
go e nmen
unding
comes
om
cen al
go -
e nmen
ans e s.
These
ans e
schemes
mus
be
ca e ully
designed
and
es
on
clea
ules
(depend
on
a iables
which
a e
no
easy
o
local
go e nmen s
o
manipula e)
so
as
o
a oid
mo al
haza d
leading
o
excess
expendi u es.
Indeed,
as
he
cen al
go e nmen
is
unable
o
dis inguish
he
sou ces
o
high
spending
be ween
highe
needs
and
ine ficiencies,
sub-
cen al
go e nmen s
ha e
an
incen i e
o
hide
hei
ue
needs
o
ob ain
highe
financing
om
he
cen al
au ho i y.
To
sum
up,
he
heo e ical
li e a u e
does
no
p o ide
a
defini i e
answe
abou
he
impac
o
decen aliza ion
on
heal h
policies.
The
high
conce n
in
many
coun ies
o
equi y
78
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(1):74–83
Table
1
–
Li e a u e
e iew:
impac
o
decen aliza ion.
1s
au ho Coun y Objec i e Pe iod
o
he
da a
Decen aliza ion
indica o Main
esul s
Zhong (2010) Canada
Impac
o
he
in oduc ion
o
a
highe
deg ee
o
decen aliza ion
on
equi y
in
heal h
ca e
u iliza ion
1994/95
1998/99
2000/01
In oduc ion
o
Heal h
and
Social
T ans e
in
1996/97,
i.e.,
la ge
block
unding
o
p o inces
Mos
inequi y
in
heal h
ca e
use
is
explained
by
a ia ions
wi hin
p o inces.
An
inc ease
in
decen aliza ion
lead
o
lowe
o e all
and
wi hin-p o ince
inequi y
in
GP
and
hospi al
se ices
and
lowe
be ween-p o ince
a ia ion
in
GP,
hospi al
and
specialis
se ices
Sche fle (2006
S.) USA/Cali o nia
Impac
o
highe
decen aliza ion
o
men al
heal h
ca e
se ices
on
uninsu ed
heal h
spending
1989–2000
Decen aliza ion
o
heal h,
men al
heal h,
and
social
se ices
(g ea e
financial
flexibili y
and
esponsibili y)
om
he
Cali o nia
s a e
o
coun ies
(p og am
ealignmen
in oduced
he
abili y
o
ans e
unds
be ween
p og ams
–
men al
heal h,
social
se ices
and
gene al
heal h)
Coun y
spending
on
men al
heal h
se ices
dec eased
a e
p og am
ealignmen .
Coun ies
wi h
abo e
median
heal h
e enues
a e
less
likely
o
make
a
ans e
o
ano he
p og am.
Wi h
ealignmen ,
coun ies
showed
he
same
le el
o
commi men
and
suppo
wi h
men al
heal h
se ices,
since
di e ed
unds
wen
mainly
o
men al
heal h
se ices
wi hin
he
ealignmen
p og ams
package
Jiménez-Rubio (2011A) 20
OECD
coun ies
Impac
o
decen aliza ion
on
heal h
s a us
(in an
mo ali y)
1970–2001
Decen aliza ion
measu ed
as:
(i)
Sha e
o
au onomous
ax
e enue
o
SCG
o e
he
CG
ax
e enue.
(ii)
Sha e
o
o al
(au onomous
o
no )
SCG
ax
o e
he
o al
e enue
Nega i e
and
significan
ela ionship
be ween
fiscal
decen aliza ion
and
in an
mo ali y,
i
a
subs an ial
deg ee
o
au onomy
in
he
sou ces
o
e enue
is
de ol ed
o
sub-cen al
go e nmen s
P ie o (2012) Spain
Es ima e
de e minan s
o
egional
heal h
ca e
expendi u e,
in
pa icula
he
deg ee
o
egional
au onomy
1992–2005
Regions
clus e ed
acco ding
o
he
deg ee
o
au onomy:
(i)
Expendi u e
and
high
fiscal
au onomy.
(ii)
Expendi u e
and
low
fiscal
au onomy.
(iii)
No
au onomy
GDP/capi a
has
mo e
influence
on
HCE
in
egions
wi h
highe
ax
au onomy,
maybe
due
o
equaliza ion
e o s
o
Spanish
NHS.
Decen aliza ion
wi hou
inequali y
is
possible
wi h
fiscal
equaliza ion.
I
high
di e ences
in
weal h
and
weak
equaliza ion
among
egions,
decen aliza ion
leads
o
inequali y
Bo dignon (2009
B.) I aly
Impac
o
egions’
bailou
expec a ions
on
unding
by
CG;
impac
o
egions’
bailou
expec a ions
on
HCE
(mid-90s),
de e minan s
o
egions’
bailou
expec a ions
1990–1999
Regions’
bailou
expec a ions
based
on
ex e nal
cons ain s
in
he
mid-90s:
coun ies’
e alua ion
o
en e ing
he
EURO
(1997),
index
o
public
budge
igh ness,
Maas ich
ules
(1994)
HCE
is
influenced
by
egional
financing,
which
is
in
u n
influenced
by
bailou
expec a ions
om
he
CG.
Lowe
expec a ions
o
bailing
ou
gene a e
a
s onge
link
be ween
ex-an e
financing
and
egional
HCE.
Riche
and
mo e
au onomous
egions
ha e
lowe
expec a ions
o
CG
in e en ion,
hence
hey
a e
mo e
financially
esponsible.
The
CG
is
also
mo e
p one
o
cu
financing
o
egions
unde
lowe
bailou
expec a ions
because
he
commi men
o
cu
HCE
will
be
aken
se iously
F ed iksson (2008
F.) Sweden Es ima e
c oss-coun ies
di e ences
in
suppo ing
he
“Pa ien
Choice
Recommenda ion”,
i.e.,
coun ies’
willingness
o
a o
o
no
he
pa ien ’s
choice
o
specialis
2001–2005
Recommenda ion
by
he
CG
can
be
mo e
o
less
suppo ed
by
coun ies,
which
ha e
la ge
compe ences
in
he
heal h
sec o
High
a ia ion
on
suppo
o
he
Pa ien
Choice
Recommenda ion
among
coun y
councils.
Abili y
o
choose
heal hca e
p o ide
a ies
acco ding
o
coun y,
c ea ing
inequali ies
in
access
o
ca e

e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(1):74–83
79
Table
1
(Con inued)
1s
au ho
Coun y
Objec i e
Pe iod
o
he
da a
Decen aliza ion
indica o
Main
esul s
López-Casasno as (2007
L.-C.) 110
egions
in
8
OECD
coun ies
Measu e
he
de e minan s
o
HCE
accoun ing
o
egional
e ec s
1997
No
indica o
o
decen aliza ion
bu
accoun
o
possible
egional
di e ences
in
HCE
An
inc ease
on
he
pe cen age
o
people
wi h
mo e
han
65
yea s
and
in
he
pe cen age
o
public
heal h
expendi u es
inc eases
HCE.
Be ween
coun ies
a iabili y
o
expendi u es
is
smalle
han
wi hin
coun y
a ia ions.
Income
elas ici y
o
HCE
is
low
and
inc eases
wi h
a ia ion
in
HCE
Cos a-Fon (2007
C.-F.) Spain
Measu e
spa ial
spillo e s
in
HCE
(in e -ju isdic ion
in e ac ions
in
defining
HCE)
2003
Compa e
egions
wi h
(i)
fiscal
and
poli ical
au onomy
(Na a a
and
Basque
coun y);
(ii)
poli ical
au onomy
(Ca alonia,
Galicia,
Andalucía,
Cana ias
and
Valencia);
(iii)
no
au onomy
E idence
o
spa ial
co ela ion.
Highe
HCE
when
egions
ha e
highe
poli ical
decen aliza ion
and
e en
highe
i
hey
ha e
also
fiscal
decen aliza ion.
Highe
HCE
i
egion
and
CG
a e
uled
by
he
same
pa y
Cos a-i-Fon (2005
C.-i.-F.) Spain
Measu e
income- ela ed
in a- egional
inequali ies
in
sel - epo ed
heal h,
and
i s
ela ion
wi h
he
deg ee
o
decen aliza ion
1997
Compa e
egions
wi h
(i)
fiscal
and
poli ical
au onomy
(Na a a
and
Basque
coun y);
(ii)
poli ical
au onomy
(Ca alonia,
Galicia,
Andalucía,
Cana ias
and
Valencia);
(iii)
no
au onomy
O e all
inequali y
is
low.
De olu ion
does
no
a o
in e - egion
inequali y.
By
con as
de olu ion
seems
o
a o
p o-equi y
policies:
inequali y
is
he
highes
in
egions
wi hou
au onomy
(INSALUD)
C i elli (2006
C.) Swi ze land
Measu e
de e minan s
o
public
HCE
accoun ing
o
egional
(can ons)
e ec s
1996–2001
No
indica o
o
decen aliza ion
bu
accoun
o
possible
egional
di e ences
in
HCE
Di e ences
in
HCE
ela ed
o
usual
ac o s
bu
in
pa icula
o
physician
densi y.
S ong
di e ences
in
HCE
ac oss
can ons
explained
in
pa
by
di e ences
in
supply
Cos a-Fon (2009
C.-F.) Spain
Impac
o
decen aliza ion
on
HCE,
in e dependency
be ween
neighbo
municipali ies
and
measu e
income
e ec
a
egional
le el
1995–2002
Indica o s
o
decen aliza ion
deg ee
and
i s
e olu ion
ac oss
ime,
owa d
cu en
si ua ion:
(i)
fiscal
and
poli ical
au onomy
(Na a a
and
Basque
coun y);
(ii)
poli ical
au onomy
(Ca alonia,
Galicia,
Andalucía,
Cana ias,
Valencia);
(iii)
no
au onomy
Poli ical
decen aliza ion
inc eases
HCE
in
he
sho
e m
bu
p oduces
cos
sa ings
in
he
long
un
(sunk
cos
o
decen aliza ion
and
expe ience
e ec s).
Highe
expendi u es
a e
ela ed
o
highe
fiscal
au onomy.
Exis ence
o
spa ial
co ela ion.
Low
impac
o
income
on
HCE,
hence
decen aliza ion
is
no
associa ed
o
s ong
egional
inequali ies
Can a e o (2005
C.) Spain
Measu e
de e minan s
o
public
HCE
accoun ing
o
egional
e ec s
1993–1999
Compa e
egions
wi h
(i)
fiscal
and
poli ical
au onomy
(Na a a
and
Basque
coun y);
(ii)
poli ical
au onomy
(Ca alonia,
Galicia,
Andalucía,
Cana ias,
Valencia);
(iii)
no
au onomy
Regional
income
and
supply
ha e
low
impac
on
HCE,
while
ageing
is
mo e
ele an .
Hence
lowe
income- ela ed
inequali y
is
expec ed
Jiménez-Rubio (2011) Canada
Impac
o
fiscal
decen aliza ion
on
heal h
ou comes
(in an
mo ali y)
1979–1995
Fiscal
decen aliza ion
is
measu ed
as
he
p opo ion
o
sub-na ional
heal h
spending
o e
o al
heal h
expendi u e
Significan
and
subs an ially
lowe
in an
mo ali y
ela ed
o
highe
fiscal
decen aliza ion
(1%
inc ease
in
fiscal
decen aliza ion
dec eases
in an
mo ali y
by
10%)
Giannoni (2002) I aly
Measu e
de e minan s
o
HCE
accoun ing
o
egional
e ec s,
and
impac
o
1992
cos -con ainmen
e o ms
1980–1995
No
indica o
o
decen aliza ion
bu
accoun
o
possible
egional
di e ences
in
HCE
S ong
impac
o
egional
income
on
HCE
and
ele an
a ea
clus e
di e ences.
Cos -con ainmen
e o ms
did
no
al e
mos
egional
di e ences
in
HCE
and
wo sened
he
si ua ion
o
some
egions
below
he
a e age
80
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(1):74–83
Table
1
(Con inued)
1s
au ho
Coun y
Objec i e
Pe iod
o
he
da a
Decen aliza ion
indica o
Main
esul s
Can a e o (2008
C.) Spain
Impac
o
fiscal
decen aliza ion
on
heal h
ou comes
(in an
mo ali y
and
li e
expec ancy)
1992–2003
Fiscal
decen aliza ion
is
measu ed
as
he
p opo ion
o
sub-na ional
heal h
spending
o e
o al
heal h
expendi u e
Decen aliza ion
significan ly
educes
in an
mo ali y
and
inc eases
li e
expec ancy
Di
Ma eo (1998) Canada
Measu e
de e minan s
o
HCE
accoun ing
o
egional
(p o inces)
e ec s
1965–1991
No
indica o
o
decen aliza ion
bu
accoun
o
possible
egional
di e ences
in
HCE
HCE
highly
ela ed
o
pe
capi a
income
(bu
elas ici y
below
1),
ageing
and
ede al
ans e s.
Reflec s
p o incial
HCE
eflec s
ans e s
om
CG
which
howe e
do
no
co ec
egional
income
disc epancies
Jiménez-Rubio (2008
J.-R.) Canada
Measu e
income- ela ed
inequali ies
in
heal h
and
heal h
ca e
use
ac oss
egions
(p o inces)
2001
No
indica o
o
decen aliza ion
bu
measu e
egional
di e ences
in
inequali ies
Heal h
ca e
use
inequali ies
a e
d i en
by
be ween-p o inces
a ia ion.
Inequali ies
in
heal h
a e
mos ly
d i en
by
wi hin-p o inces
a ia ion.
Di e en
esul s
o
heal h
and
heal h
ca e
inequali ies
seem
o
sugges
o he
heal h
de e minan s
a he
han
heal h
ca e
access
a e
essen ial
o
explain
inequali ies
HCE,
heal h
ca e
expendi u es;
CG,
cen al
go e nmen ;
SCG,
sub-cen al
go e nmen ;
GP,
gene al
p ac ice;
AC,
au onomous
communi ies.
in
heal h
is
a
majo
a gumen
agains
decen aliza ion,
unless
s ong
solida i y
mechanisms
a e
pu
in
place.
The
con a-
dic o y
expec a ions
abou
e ficiency
equi e
ca e ul
empi ical
alida ion.
In
hese
imes
o
ad e se
economic
ci cums ances,
e ficiency
is
mo e
han
e e
a
majo
issue
in
decision-making,
and
s ong
e idence
is
necessa y
be o e
ad oca ing
o
decen-
aliza ion
in
heal h.
Empi ical
e idence
In
o de
o
ge
an
exhaus i e
o e iew
on
empi ical
e idence,
we
pe o med
a
sys ema ic
li e a u e
e iew.
We
conduc ed
a
compu e ized
li e a u e
sea ch
in
PubMed
(Na ional
Cen e
o
Bio echnology
In o ma ion,
Be hesda,
Ma yland)
and
Google
Schola ,
supplemen ed
by
a
sea ch
o
quo ed
e e ences.
Tex
keywo ds
used
in
he
sea ch
included
decen aliza ion,
ede -
alism,
heal h,
heal h
ca e,
equi y,
and
e ficiency.
We
es ic ed
ou
analysis
o
hose
pe o med
in
OECD
coun ies
o
allow
o
ele an
compa isons,
ha
is,
in
a
compa able
con ex .
We
only
included
empi ical
s udies
abou
he
impac
o
decen-
aliza ion,
hence
excluding
heo e ical
s udies,
s udies
abou
legisla ion
o
abou
poli ical
o
o ganiza ional
aspec s
o
decen aliza ion,
edi o ials
and
li e a u e
e iews.
The
sea ch
was
limi ed
o
English-language
a icles
published
om
1995
o
July
2012,
when
decen aliza ion
in
heal h
has
become
a
el-
e an
and
applied
policy
op ion
in
OECD
coun ies.
Ou
sea ch
allowed
collec ing
17
pape s,
whose
main
cha ac e is ics
and
esul s
a e
displayed
in
Table
1.
S udies
we e
di ided
acco ding
o
dis inc
analyzes,
based
on
he
mos
ele an
decen aliza-
ion
ou comes,
namely
inequali ies
in
heal h
and
heal h
ca e,
heal h
expendi u es
and
heal h
ou comes.
Inequali y
in
heal h
and
heal h
ca e
use
The
consequences
o
decen aliza ion
on
inequali y
we e
he
main
issue
analyzed
by
Zhong13,
Jiménez-Rubio
e
al.1,
Cos a-
i-Fon 26 and
F ede iksson
and
Winblad27.
Zhong13 ound
ha
in
Canada
inequali ies
in
heal h
ca e
use
(o e all,
wi hin
p o inces
and
be ween
p o inces)
dec eased
a e
decen al-
iza ion.
Mos
inequali y
was
explained
by
wi hin-p o inces
a ia ion,
while
be ween-p o inces
a ia ions
did
no
much
con ibu e
o
inequali y.13 By
con as ,
Jiménez-Rubio
e
al.1
also
using
da a
om
Canadian
p o inces
obse ed
ha
income- ela ed
inequali ies
in
heal h
ca e
use
esul ed
om
be ween-p o inces
a ia ions
while
income- ela ed
inequali-
ies
in
heal h
we e
ela ed
o
wi hin- egion
a ia ions.
While
Zhong13 used
an
o e all
inequi y
measu e,
Jiménez-Rubio
e
al.1used
an
income- ela ed
one,
which
possibly
explains
he
disc epan
esul s.
The
esul s
by
Jiménez-Rubio
e
al.1
ce ainly
ques ion
he
equaliza ion
scheme
ac oss
p o inces;
he
edis ibu ion
o
unds
om
iche
o
poo e
p o inces
does
no
seem
o
a oid
inequi y
in
heal h
ca e
use
ela ed
o
be ween-p o ince
a ia ions
( o
example,
heal h
ca e
use
is
lowe
in
Quebec
ha
has
a
lowe - han-a e age
income
pe
capi a).
As
he
au ho
emphasizes,
ad oca es
o
decen al-
iza ion
would
howe e
conside
hese
di e ences
as
ela ed
o
di e en
p e e ences,
hence
legi ima e.
Income- ela ed
inequi y
in
heal h
was
mos ly
ela ed
o
di e ences
be ween
ich
and
poo
people
wi hin
p o inces,
he e
ques ioning
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(1):74–83
81
he
e o s
by
p o inces
o
educe
inequali ies
(would
a
cen al
go e nmen
be
mo e
commi ed
o
educe
inequi y
in
heal h?).
Fo
Spain,
Cos a-i-Fon 26 ound
a
small
o e all,
wi hin
and
be ween
egions
income- ela ed
inequali y
in
heal h,
al hough
somewha
highe
in
egions
wi h
lowe
au onomy.
The
au ho
explains
his
di e ence
by
he
g ea e
ole
o
he
p i a e
sec o
in
hose
egions.
He
also
emphasizes
ha
decen aliza ion
may
ha e
a o ed
equi y
due
o
a
high
commi men
o
egions
o
achie e
his
objec i e,
which
co esponds
o
a
high
ci izens’
conce n.
Finally,
F ed iks-
son
and
Winblad27 s udied
a
specific
e o m
owa d
mo e
p o ide
choice
in
Sweden,
whe e
heal h
ca e
use
is
highly
decen alized
a
he
coun y
le el.
The
au ho
showed
ha
while
some
coun ies
suppo ed
he
e o m
h ough
a o ing
choice,
o he s
implemen ed
adminis a i e
ba ie s
agains
i .
The e o e,
au onomy
on
decision
making
( ega ding
p o ide
choice)
esul ed
on
inequali ies
be ween
people
li ing
in
di e en
Swedish
coun ies.
Heal h
expendi u es
Inequali y
ela ed
o
decen aliza ion
was
also
obse ed
indi-
ec ly,
h ough
examining
he
impac
o
egional
GDP
pe
capi a
on
heal h
ca e
expendi u es.
Indeed,
a
g ea e
impac
o
egional
income
on
heal h
ca e
expendi u e
would
mean
ha
iche
egions
spend
significan ly
mo e
on
heal h
han
poo
ones,
hence
c ea ing
inequali ies
in
heal h
ca e
use.
Al hough
all
s udies
using
egional
da a
conclude
ha
heal h
ca e
expendi u es
do
no
a y
much
wi h
income
( he
elas ici y
wi h
espec
o
income
is
below
one),
esul s
a e
con as ed
and
a y
be ween
coun ies.
Fo
Spain,
P ie o
and
Lago-Pe ˜
nas28
ound
a
posi i e
ela ion
be ween
income
and
public
heal h
expendi u es
only
in
egions
wi h
highe
fiscal
au onomy.
Regions
wi hou
fiscal
au onomy
benefi ed
om
na ional
equaliza ion
e o s
and
he e o e
managed
o
achie e
high
le els
o
heal h
ca e
expendi u es
despi e
o
lowe
income.
The
low
impac
o
income
on
heal h
ca e
expendi u es
in
Spain
was
confi med
by
Can a e o,
Cos a-i-Fon
and
Moscone.29,11
The
same
conclusion
could
be
d awn
o
Canada,21 al hough
he
impac
o
income
on
heal h
expendi u es
was
g ea e
han
in
Spain.
Using
a
specific
indica o ,
Di
Ma eo
and
Di
Ma eo30
showed
he
posi i e
impac
o
ede al
ans e s
on
heal h
ca e
expendi u e.
Tha
is,
ede al
ans e s
ce ainly
educe
he
impac
o
egional
income
on
expendi u es
bu
do
no
ully
co ec
egional
income
disc epancies.
The
pic u e
is
some-
wha
di e en
in
I aly,
whe e
egional
income
had
a
s ong
impac
on
heal h
ca e
expendi u es.31 The
au ho s
showed
also
ha
cos -con ainmen
measu es
ha e
no
al e ed
c oss-
egional
di e ences
in
heal h
ca e
expendi u es
and
ha e
e en
wo sened
hem
in
some
cases.
Fo
Swi ze land,
C i elli
e
al.32 obse ed
a
la ge
impac
o
physician
supply,
which
is
highly
a iable
ac oss
egions,
on
heal h
ca e
expendi u es.
Hence
c oss- egional
di e ences
in
heal h
ca e
supply
may
also
be
a
sou ce
o
inequali y
ac oss
egions.
Finally,
using
da a
om
110
egions
o
8
OECD
coun ies,
Lopez-Casasno as
and
Saez33 showed
a
low
elas ici y
o
heal h
ca e
expendi u e
wi h
espec
o
income.
Howe e ,
he
impac
o
income
was
highe
ac oss
egions
in
coun ies
wi h
highe
in e - egional
income
inequali ies,
leading
in
u n
o
highe
disc epancies
in
heal h
ca e
expendi u es.
Sche fle
and
Smi h34,
Cos a-i-Fon
and
Moscone11,
Cos a-
i-Fon
and
Pons-No ell22 add essed
he
impac
o
decen al-
iza ion
on
heal h
expendi u es,
while
Bo dignon
and
Tu a i35
examined
he
impac
o
he
in e ac ion
be ween
cen al
and
sub-cen al
go e nmen s.
Sche fle
and
Smi h34 showed
o
Cali o nia
ha
spending
on
uninsu ed
pa ien s
dec eased
wi h
he
highe
coun ies’
au onomy
in
alloca ing
unds
ac oss
heal h
and
social
p og ams.
Cos a-Fon
and
Pons-No ell22
obse ed
ha
Spanish
egions
wi h
bo h
poli ical
and
fis-
cal
au onomy
had
highe
heal h
expendi u es
as
compa ed
o
egions
wi hou
au onomy
o
wi h
poli ical
au onomy
only.
Cos a-i-Fon
and
Moscone11 obse ed
howe e
ha
decen aliza ion
inc eased
expendi u es
only
in
he
sho
un,
p oducing
sa ings
in
he
long
un.
They
a gued
ha
fi s ly
decen aliza ion
inc eased
heal h
ca e
cos s
due
o
sunk
cos s;
hen
his
e ec
was
minimized
in
he
long
un
by
an
expe ience
cu e,
ha
is,
lea ning-by-doing
allowed
educing
cos s.
Rega ding
assump ions
om
economic
he-
o y,
Cos a-i-Fon
and
Moscone11 also
showed
he
exis ence
o
spa ial
co ela ion
o
heal h
ca e
expendi u es
be ween
neighbo
ju isdic ions,
sus aining
he
assump ion
o
ho izon-
al
spillo e s.
This
esul
may
hence
be
due
o
compe i ion
be ween
neighbo
ju isdic ions
o
inc ease
a ac i eness
o
due
o
poli icians
being
judged
based
on
he
neighbo
coun-
e pa s’
ac ions.
Finally,
Bo dignon
and
Tu a i35 used
1990s
I alian
adjus -
men
p ocess
imposed
by
an
ex e nal
en i y
( he
Eu opean
Union)
o
unde s and
he
ole
o
expec a ions
and
he
s a e-
gic
in e ac ions
be ween
he
cen al
s a e
and
egions,
using
da a
on
heal h
ca e
expendi u es.
Regions
expec ing
ha
he
cen al
go e nmen
will
in e ene
in
case
o
deb
so ened
hei
budge
cons ain s
and
he
ela ionship
be ween
he
unding
hey
ecei e
om
he
cen al
go e nmen
and
heal h
expendi u es
was
lowe .
By
con as ,
du ing
ex e nal
adjus -
men ,
he
cen al
go e nmen
was
pe cei ed
as
mo e
s ingen
and
he
link
be ween
unding
and
expendi u es
became
s onge .
And
he
cen al
go e nmen
was
also
mo e
p one
o
cu
unding
o
egions
because
i
knew
i s
commi men
no
o
bailou
would
be
aken
mo e
se iously.
In e es ingly,
au ho s
showed
ha
mo e
au onomy
lead
o
mo e
finan-
cially
esponsible
policies
because
expec a ions
o
bailou
we e
low.
This
pape
hus
emphasized
ha
ans e
mecha-
nisms,
which
a e
always
p esen
in
decen alized
coun ies,
c ea ed
incen i es
ha
may
be
mo e
o
less
de imen al
o
e ficiency
depending
on
how
hey
a e
designed
and
pu
in
p ac ice.
Heal h
esul s
Resul s
abou
he
impac
o
decen aliza ion
on
heal h
ou comes
a e
sca ce
bu
consis en
ac oss
s udies.
Jiménez-
Rubio12,36 and
Can a e o
and
Pascual37 ag ee
on
iden i ying
a
posi i e
ela ionship
be ween
fiscal
decen aliza ion
and
heal h
esul s,
measu ed
h ough
in an
mo ali y.
Can a e o
and
Pascual37 used
an
al e na i e
measu e
o
heal h
s a us
(li e
expec ancy)
which
confi med
he
posi i e
con ibu ion
o
decen aliza ion
o
heal h
s a us.
82
e
p
o
s
a
ú
d
e
p
ú
b
l
i
c
a
.
2
0
1
3;3
1(1):74–83
Conclusion
Al hough
he
economics
li e a u e
has
la gely
discussed
he
impac
o
decen aliza ion,
empi ical
esul s
emain
sca ce,
in
pa icula
ega ding
decen aliza ion
in
heal h.
Ne e he-
less,
decen aliza ion
o
heal h
policies
and
unding
has
been
la gely
implemen ed
in
a ious
coun ies
and
is
gene ally
con-
side ed
as
a
ele an
op ion
o
imp o e
e ficiency
in
heal h
ca e.7
Ou
e iew
o
he
li e a u e
allows
d aw
p elimina y
conclusions,
based
on
ela i ely
ecen
decen aliza ion
expe-
iences,
in
pa icula
in
Canada,
I aly,
Spain
and
Swi ze land.
Fi s
and
o emos ,
de olu ion
o
poli ical
(and
fiscal)
au ho -
i y
o
sub-go e nmen
le els
seems
o
inc ease
heal h
ca e
expendi u es
bu
also
imp o e
heal h
ou comes,
mainly
mea-
su ed
h ough
in an
mo ali y
a e.
Acco ding
o
economic
heo y,
decen aliza ion
may
os e
compe i ion
be ween
ju isdic ions
o
inc ease
a ac i eness,
and
inc ease
p essu e
on
local
go e nmen s
because
ci izens
e alua e
hei
pe o -
mance
based
on
neighbo
coun e pa s’
ac ions.
The
empi ical
li e a u e
sugges s
ha
enhanced
compe i ion
p omp s
local
decision-make s
o
inc ease
heal h
ca e
expendi u es
( ace
o
he
op)
and
no
he
e e se
in
o de
o
dec ease
axes
( ace
o
he
bo om),
wi h
a
a o able
impac
on
heal h.
The
case
o
Spain
is
pa icula ly
enligh ening,
which
shows
ha
he
inc ease
in
heal h
ca e
expendi u es
has
been
he
highes
in
egions
wi h
fiscal
au onomy.
This
esul
may
eflec
he
high
people’s
demand
o
high-quali y
heal h
se ices,
and
he
highe
esponsi eness
o
local
au ho i ies
o
his
p e e ence.
The
highe
heal h
ca e
expendi u es
unde
decen aliza ion
may
howe e
eflec
also
highe
cos s,
ela ed
o
ins ance
o
duplica ion
o
inpu s
( wo
neighbo
egions
o e ing
simila
se ices
which
could
be
sha ed),
diseconomies
o
scale,
o
he
sunk
cos s
associa ed
o
implemen a ion
o
a
local
heal h
p o-
ision
scheme.
To
some
ex en ,
ad e se
incen i es
may
play
some
ole
i
sub-cen al
go e nmen s
a e
no
ully
financially
esponsible
o
hei
expendi u es.
In
pa icula ,
mo al
haz-
a d
may
exis
i
sub-cen al
go e nmen s
expec
hei
deb s
being
co e ed
by
he
cen al
s a e
(bailou )
o
i
hei
budge
depends
mo e
la gely
om
ans e s
om
he
cen al
s a e.
In
a
ew
wo ds,
decen aliza ion
does
no
appea
a
fi s
sigh
as
a
means
o
con ol
o
educe
heal h
ca e
expendi u es,
bu
as
an
incen i e
o
p o ide
be e
and
possibly
mo e
expensi e
se ices.
The
e ficiency
consequences
a e
hus
ambiguous,
as
i
is
unclea
whe he
addi ional
benefi s
–
measu ed
h ough
a
e y
educed
numbe
o
indica o s
–
a e
wo h
addi ional
cos s.
Rega ding
equi y,
empi ical
esul s
a e
ambiguous
and
ce ainly
ela ed
o
he
specific
coun ies’
con ex .
Inequi y
in
heal h
and
heal h
ca e
is
low
in
Spain,
whe e
heal h
expendi u es
a e
also
poo ly
ela ed
o
he
egion
GDP/capi a.
Addi ionally,
inequi y
in
heal h
ca e
seems
o
be
lowe
in
mo e
au onomous
egions,
so
ha
decen aliza ion
may
ha e
a o ed
equi y.
In
Canada,
income- ela ed
inequi y
in
heal h
ca e
is
ela ed
o
be ween-p o inces
inequali ies.
In
I aly
and
Swi ze land,
he e
is
a
s ong
ela ionship
be ween
egions
( esp.
can ons)
income
and
heal h
ca e
expendi u es,
esul -
ing
in
a
la ge
he e ogenei y
in
heal h
ca e
expendi u es.
These
esul s
may
ce ainly
be
ela ed
o
lowe
equalizing
mechanisms
in
hese
wo
coun ies
coupled
wi h
a
highe
fiscal
au onomy.
No e
also
ha
di e en
decisions
ac oss
egions,
namely
abou
physicians
o
equipmen
supply,
also
po en ially
c ea e
di e ences/inequi y
in
heal h
ca e
deli e y.
To
conclude,
solida i y
mechanisms
ac oss
sub-cen al
au ho i ies
a e
ele an
o
a oid
he
eme gence
o
la ge
inequali ies
ac oss
egions
in
heal h
ca e
deli e y
and
expend-
i u es.
Howe e ,
edis ibu ion
o
unds
also
educes
ju is-
dic ions’
financial
esponsibili y,
wi h
possible
de imen al
consequences
on
expendi u es
and
ambiguous
consequences
on
e ficiency.
This
las
aspec
is
o
pa icula
impo ance
i
ju isdic ions
compe e
wi h
each
o he
o
p o iding
high-
quali y
se ices
and
no
h ough
lowe ing
ax
a es.
Funding
This
in es iga ion
was
unded
by
he
Fundac¸ão
pa a
a
Ciência
e
a
Tecnologia
h ough
he
p ojec
PTDC/EGE-
ECO/104094/2008.
Conflic s
o
in e es
The
au ho s
decla e
ha
he e
a e
no
conflic s
o
in e es s.
e
e
e
n
c
e
s
1.
Jiménez-Rubio
D,
Smi h
P,
Doo slae
E.
Equi y
in
heal h
and
heal h
ca e
in
a
decen alised
con ex :
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Canada.
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2008;17:377–92.
2.
Oa es
W.
Fiscal
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New
Yo k:
Ha cou
B ace
Jo ano ich;
1972.
3.
Iimi
A.
Decen aliza ion
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g ow h
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an
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J
U ban
Econ.
2005;57:449–61.
4.
Rod iguez-Pose
A,
Ezcu a
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o
egional
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J
Econ
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2010;10:619–44.
5.
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S,
Ge le
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