0212/2025 - A descentralização fiscal pode quebrar um Sistema Nacional de Saúde
Fiscal decentralisation can break a National Health System
Author:
• Arianna Rotulo - Rotulo, A - <a.rotulo@rug.nl>ORCID: https://orcid.org/0000-0001-8752-6889
Abstract:
Esta carta defende com urgência a necessidade de desenvolver vontade política para reverter a descentralização fiscal. Um sistema de saúde fiscalmente descentralizado aprofunda as desigualdades regionais e privatiza os serviços públicos por meio de terceirização, mobilidade de pacientes e autonomia hospitalar. Regiões desfavorecidas dependem de provedores privados, enquanto a competição por financiamento desestabiliza a equidade. Reverter essa política é crucial para garantir cuidados de saúde universais e acessíveis a todos.Keywords:
descentralização fiscal; Sistema Nacional de Saúde; Regionalism; PrivatizaçãoContent:
In January, The Lancet Regional Health – Europe published an editorial(1) 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 services(2). This happens at local levels through reductions in healthcare capacity, introduction of new out-of-pocket-payments, methodical outsourcing of services, and hospital autonomisation(3). 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 models(4).
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 others(4).
With its heavily fiscally decentralised healthcare model, Italy stands as a stark example of these practices and of their shortcomings(5). While naming(4) and studying(5) 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. The Lancet Regional Health - Europe. 2025 Jan;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. The Lancet Public Health. 2022 Jul;7(7):e638–46.
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 Sep 20;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 Nov;34(4):258–68.
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 Nov 28;1.
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 services(2). This happens at local levels through reductions in healthcare capacity, introduction of new out-of-pocket-payments, methodical outsourcing of services, and hospital autonomisation(3). 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 models(4).
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 others(4).
With its heavily fiscally decentralised healthcare model, Italy stands as a stark example of these practices and of their shortcomings(5). While naming(4) and studying(5) 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. The Lancet Regional Health - Europe. 2025 Jan;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. The Lancet Public Health. 2022 Jul;7(7):e638–46.
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 Sep 20;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 Nov;34(4):258–68.
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 Nov 28;1.