Arianna Rotulo - Global Public Health Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
Christina Paraskevopoulou - School of Social Sciences, Panteion University of Social and Political Sciences, Athens, Greece
Elias Kondilis - Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece

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 ۲۰۰۱, 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 ۲۰۰۱ and ۲۰۱۷, 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.

Fiscal Decentralisation, Decentralization, Healthcare Access, Healthcare Financing, Healthcare Equity, Geographical Disparities