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Costa-Font J. and Rico A. (2006) Devolution and the interregional inequalities in health and healthcare in Spain, Regional Studies 40, 875–887. The desirability of devolution of government responsibilities is often questioned on the grounds of regional cohesion concerns. This feature is especially relevant in welfare policy areas such as healthcare services given their impact on an individual's well-being. This paper examines the effects of health system devolution on the emergence of inter-territorial inequalities in healthcare outcomes (mortality) and outputs (healthcare expenditure) in the Spanish National Health System (NHS). Based on an empirical model for regional health expenditure, and drawing from a battery of inequality indicators (some taken from previous studies, other estimated anew), the following results are obtained. First, healthcare devolution has not led to an expansion of regional inequalities in healthcare outcomes and outputs. Second, there is no clear-cut evidence that devolution increases public health expenditure (in real terms) in devolved region-states, with the exception of fiscally accountable autonomous communities (ACs). Finally, regional health expenditure is explained by differences in need and higher reliance healthcare inputs use, size effects as well as the region-specific economic and demographic dimension in addition to regional income.
Costa-Font J. et Rico A. (2006) La régionalisation et les inégalités de santé et des services médicaux en Espagne, Regional Studies 40, 875–887. Souvent on remet en question les avantages de la régionalisation des compétences gouvernementales en raison des questions qui se posent quant à la cohésion régionale. Cela est particulièrement pertinent dans le domaine des politiques en faveur des services médicaux, étant donné leur impact sur le bien-être de l'individu. Cet article cherche à examiner les retombées de la régionalisation des services de santé sur la naissance des inégalités des résultats des services médicaux (mortalité) et des rendements (dépenses de santé) dans la Sécurité Sociale espagnole. A partir d'un modèle économétrique des dépenses de santé, et puisant dans une batterie d'indices d'inégalité (dont certains proviennent des études antérieures et dont d'autres sont de nouvelles estimations), on obtient les résultats suivants. Primo, la régionalisation des services médicaux n'a entraîné un creusement des inégalités régionales ni des résultats, ni des rendements des services médicaux. Secundo, il reste à prouver que la régionalisation augmente les dépenses de santé publique (en termes réels), à l'exception des AC qui sont fiscalement autonomes. Pour conclure, on explique les dépenses de santé régionales en termes du besoin et de l'utilisation des facteurs médicaux dont on dépend davantage, des effets de taille ainsi que des dimensions économique et démographique spécifiques d'une région en plus du revenu régional.
Inégalités régionales Interactions politiques Responsabilité politique Sécu
Costa-Font J. und Rico A. (2006) Dezentralisierung und die von Region zu Region zu beobachtenden Unterschiede der Gesundheit und Gesundheitsfürsorge in Spanien, Regional Studies 40, 875–887. Auf Grund der Besorgnis um regionale Kohäsion fragt man sich oft, ob die Dezentralisierung der Regierungsverantwortlichkeit wünschenswert ist. In Anbetracht der Auswirkung auf das Wohlergehen individueller Personen betrifft dieser Aspekt besonders Aufgabengebiete derWohlfahrtspolitik, wie z.B. Gesundheitsfürsorge. DieserAufsatz untersucht die Wirkung der Dezentralisierung des Gesundheitswesens auf von Region zu Region beobachteten Unterschieden in den Ergebnissen der Gesundheitsfürsorge (Sterblichkeit) und Aufwand (Ausgaben für Gesundheitsfürsorge) im Gesundheitswesen des spanischen Staates (NHS). Gestützt sowohl auf ein empirisches Modell für regionale Gesundheitsausgaben als auch eine Reihe Unterschiedsindikatoren (manche früheren Studien entnommen, andere von neueren Berechnungen) werden folgende Ergebnisse erzielt:erstens, daß die Dezentralisierung der Gesundheitsfürsorge nicht zu einer Ausweitung regionaler Unterschiede der Ergebnisse der Gesundheitsfürsorge geführt hat, und zweitens sich keine eindeutigen Beweise ergaben, daß Dezentralisierung die Ausgaben für das öffentliche Gesundheitswesen mit Ausnahme des finanziell verantwortlichen AC in zentralierten Regionalstaaten (effektiv)gestiegen sind. Abschließend werden regionale Ausgaben für das Gesundheitswesen zusätzlich regionler Einkommen durch Unterschiede in Bedarf und grösserem Verlaß auf Inanspruchnahme des Gesundheitsfürsorgeaufwands, durch Größeneffekte sowie spezifische wirtschaftliche und demographische Dimensionen erklärt.
Regionale Unterschiede Politische Wechselwirkungen Politische Verantwortlichkeit NHS
Costa-Font J. y Rico A. (2006) Transferencia de competencias y las desigualdades interregionales en la salud y la atención sanitaria en España, Regional Studies 40, 875–887. A menudo se cuestiona la conveniencia de la transferencia de las competencias del gobierno porque se teme que peligre la cohesión regional. Esta cuestión es especialmente relevante en temas de la política del bienestar tales como los servicios de atención sanitaria, puesto que tienen mucho impacto en el bienestar del individuo. En este artículo examinamos qué efectos ha tenido la transferencia de competencias del sistema de la salud en cuanto a la aparición de desigualdades interterritoriales en los resultados de la atención sanitaria (mortalidad) y la inversión (gasto de la atención sanitaria) en el sistema de la Seguridad Social en España. Basándonos en un modelo empírico para el gasto de la salud en las comunidades autónomas y según una batería de indicadores de desigualdades (algunos extraídos de estudios previos, y otros de cálculos nuevos), obtenemos los siguientes resultados. Primero, la transferencia de la competencia de atención sanitaria no ha llevado a una expansión de las desigualdades regionales en los resultados y las inversiones. Segundo, no hay pruebas claras de que la transferencia de competencias aumente el gasto de la salud pública (en términos reales) en los estados regionales con las competencias transferidas con la excepción de una contabilidad fiscalmente responsable. Para terminar, el gasto de la salud en las comunidades autónomas se explica por las diferencias en las necesidades y una mayor dependencia de la atención sanitaria, los efectos del tamaño así como la dimensión económica y demográfica de la región en cuestión, además de los ingresos regionales.
Desigualdades regionales Interacciones políticas Responsabilidad política Seguridad Social
Acknowledgements
The authors are specially thank for the helpful comments of two anonymous referees, as well as that of Elias Mossialos, Adam Oliver, Guillem López-Casasnovas and the participants of the European Health Policy Group meeting, London, UK, 2002. Joan Costa-Font is grateful for funds received from the Comisión Interministerial de Ciencia y Tecnologia, number SEJ2005-03196/ECON.
Notes
1. The economic framework underlying decentralization structures relies on the idea of a principal–agent relationship between citizens and government where the principals are the citizens/voters and the agents are the politicians.
2. Other interpretations would suggest that in multi-tiered states, decentralization exacerbates inequalities by improving the performance of the better off due to specific influence of social capital.
3. However, the perceived legitimacy and function of the regional health boards have less to do with formal structures and more to do with the timing of their formation.
4. In the US context, some argue that federal governments are generally more supportive of welfare policies than the states are (Dileo, 1996).
5. Theoretically, an NHS system should ensure that two individuals of identical income and equal needs contribute and benefit equally regardless of their location.
6. Whereas an integrated jurisdiction benefits from interregional externalities, a centralized government might be more likely to neglect minority interests.
7. Thus, one might well expect that countries that have undertaken a devolution process arguably tend to be those showing lesser degrees of (regional) inequality aversion.
8. This can be explained as: giving new responsibilities to localities encouraged local communities to put sufficient resources into their health system to provide adequate basic minimum coverage, while wealthy municipalities did not increase their spending.
9. Even though coverage is minimal for preventive programmes, long-term care and dental services, some regional diversity persists: while the Basque Country and Andalucia cover child dental care, other regions do not. Similarly, whereas long-term care is defined as a public responsibility in some regional basic statutory law (e.g. Castille-La Mancha), in other regions it is defined as an individual responsibility (e.g. Catalonia).
10. An exception to this is Catalonia, where about 60% of the inpatient centre is private (although not-for-profit). Furthermore, increasingly inpatient care all over Spain is contracted out to the private sector.
11. However, it should be noted that individuals are allowed to supplement the NHS by purchasing private health insurance (PHI), which mainly refers to a tool to supplement a certain lack of ‘perceived NHS quality’ (Costa-Font and Garcia, 2003). However, prior studies indicate that patters of PHI do not expand significantly in the period examined (Costa-Font, 2005).
12. However, given that regional government could obtain external financing from financial markets, this feature generated recurring central and regional debt (around 10% per annum on average during 1985–95).
13. The reasons for setting up a model of asymmetric federalism lie in the pre-existing differences in the management capacity of some ACs as opposed to newly created ones, as well as supply-side dissimilarities. For example, the Catalan healthcare structure relies mainly on private non-profit-making private organizations.
14. With the exception of some sanitation functions, which are carried out by local health authorities, most other public health and health promotion activities were transferred to the regions during the 1980s.
15. For certain common decisions, it draws on the input of the Inter-territorial Council of the NHS – an advisory committee comprising representatives from the central and regional governments – where coordination should legally take place.
16. In addition, the capitation formula for healthcare incorporated for the first time an age supplement calculated according to the percentage of the population over 65 years of age. Finally, the management of 40% of value added tax (VAT) plus a variable percentage (40–100%) of specific taxes (tobacco, alcohol and petrol) was also transferred to the regions.
17. This is the case of extending the NHS to dental care for children – traditionally in the hands of the private sector – in some Spanish AC while is not covered in the rest. Outside Spain, one might refer to the coverage of personal care in Scotland whereby devolution has brought the introduction of free personal care for the mentally ill, which ended with the means test for non-nursing home help (Woods, 2004).
18. In the case of Catalonia, this has been, for example, in the setting up of health technology agencies, in the purchaser–provider split, and in several experiences with long-term care. In Andalucia innovation has been in the coverage of dental care, exchange and opposition to negative lists. The Basque Country is another front runner, among other reasons due to the higher expenditure per capita at its disposal.
19. It could be argued that inequalities might emerge at the personal level. Evidence on (horizontal and vertical) inequalities at the individual level (Urbanos, 2000, 2001) indicates that horizontal inequalities in healthcare delivery at the individual level are significantly small and even seem to have declined in the 1990s (Urbanos, 2000). Whereas in primary care there were no significant individual inequalities (favouring the rich), and inequalities in specialized care have declined from 1989 to 1997. Inequalities in the delivery of care now concentrate on the area of emergency care.