Arianna Rotulo

Thesis title:

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


Introduction: Fiscal 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.Methods: This 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 discussion: Overall, 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.

First supervisor:

Elias Kondilis


3 – Health, Biopolitics & Social Inequality