Fiscal decentralisation can break a national health systemIn January, The Lancet Regional Health - Europe published an editorial1 on the challenges of Italy’s fragmented national health system. In doing so, the outlet provided the opportunity to start an evidence-based discussion on the broader implications of fiscal decentralisation - the transfer of revenue and spending powers to local authorities and providers - in national health systems.
Fiscal decentralisation not only creates fertile ground to exacerbate pre-existing disparities but is also a gateway to privatise publicly owned and/or financed health services2. This happens at local levels through reductions in healthcare capacity, introduction of new out-of-pocket-payments, methodical outsourcing of services, and hospital autonomisation3. The implications are remarkable: on the supply side, systematically underserved Regions use their local budget to buy healthcare capacity from the private sector. On the demand side, long waiting lists push patients toward private providers, either paying directly or relying on integrated insurance models4tax-funded health systems like Italian and Spanish ones reveal relevant internal patient flows, raising concerns in terms of equity, budget imbalances, and unexploited economies of scale at the regional and organizational level. However, policymakers lack effective tools to rapidly identify the causes of patient outflows in Beveridgean healthcare systems. We address the gap by conducting a critical review of the drivers of patient mobility. Elaborating on existing knowledge, we propose a concise, versatile assessment matrix to help policymakers in understanding the most relevant causes of mobility. Specifically, we identify three main categories of drivers: insufficient service availability, poor (perceived.
Inter-regional mobility is also a common solution to inaccessible, fiscally decentralised local services. Since providers and regional authorities compete against each other, inter-regional mobility not only drives up costs but also introduces a perverse dynamic where funding follows the patient, often resulting in regional profits or losses, depending on whether a region attracts or loses patients to others4tax-funded health systems like Italian and Spanish ones reveal relevant internal patient flows, raising concerns in terms of equity, budget imbalances, and unexploited economies of scale at the regional and organizational level. However, policymakers lack effective tools to rapidly identify the causes of patient outflows in Beveridgean healthcare systems. We address the gap by conducting a critical review of the drivers of patient mobility. Elaborating on existing knowledge, we propose a concise, versatile assessment matrix to help policymakers in understanding the most relevant causes of mobility. Specifically, we identify three main categories of drivers: insufficient service availability, poor (perceived.
With its heavily fiscally decentralised healthcare model, Italy stands as a stark example of these practices and of their shortcomings5The Italian National Health System (Servizio Sanitario Nazionale, SSN. While naming4tax-funded health systems like Italian and Spanish ones reveal relevant internal patient flows, raising concerns in terms of equity, budget imbalances, and unexploited economies of scale at the regional and organizational level. However, policymakers lack effective tools to rapidly identify the causes of patient outflows in Beveridgean healthcare systems. We address the gap by conducting a critical review of the drivers of patient mobility. Elaborating on existing knowledge, we propose a concise, versatile assessment matrix to help policymakers in understanding the most relevant causes of mobility. Specifically, we identify three main categories of drivers: insufficient service availability, poor (perceived and studying5. The Italian National Health System (Servizio Sanitario Nazionale, SSN the issue is important, the political will to reject fiscal decentralisation is crucial to resume the path towards universally accessible care in Italy and elsewhere.
References
- 1 The Lancet Regional Health - Europe. The Italian health data system is broken. Lancet Reg Health Eur 2025; 48:101206.
- 2 Goodair B, Reeves A. Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013-20: an observational study of NHS privatisation. Lancet Public Health 2022; 7(7):e638-e646.
- 3 Rotulo A, Paraskevopoulou C, Kondilis E. The dangers of fiscal decentralisation in healthcare: a response to the recent commentaries. Int J Health Policy Manag 2023; 12:8266.
- 4 Ricci A, Barzan E, Longo F. How to identify the drivers of patient inter-regional mobility in beveridgean systems? Critical review and assessment matrix for policy design & managerial interventions. Health Serv Manage Res 2021; 34(4):258-268.
- 5 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; 11(11):2440-2450.
