University of Granada, Spain, Facultad de Ciencias Económicas y Empresariales, s/n, 18071, Granada, Spain.
Erasmus University Rotterdam and Tinbergen Institute, The Netherlands.
Soc Sci Med. 2017 Sep;188:69-81. doi: 10.1016/j.socscimed.2017.06.041. Epub 2017 Jul 1.
While many countries worldwide are shifting responsibilities for their health systems to local levels of government, there is to date insufficient evidence about the potential impact of these policy reforms. We estimate the impact of decentralization of the health services on infant and neonatal mortality using a natural experiment: the devolution of health care decision making powers to Spanish regions. The devolution was implemented gradually and asymmetrically over a twenty-year period (1981-2002). The order in which the regions were decentralized was driven by political factors and hence can be considered exogenous to health outcomes. In addition, we exploit the dynamic effect of decentralization of health services and allow for heterogeneous effects by the two main types of decentralization implemented across regions: full decentralization (political and fiscal powers) versus political decentralization only. Our difference in differences results based on a panel dataset for the 50 Spanish provinces over the period 1980 to 2010 show that the lasting benefit of decentralization accrues only to regions which enjoy almost full fiscal and political powers and which are also among the richest regions.
虽然世界上许多国家都在将其卫生系统的责任转移到地方政府层面，但迄今为止，关于这些政策改革的潜在影响的证据还不够充分。我们利用一项自然实验来估计卫生服务权力下放对婴儿和新生儿死亡率的影响：将医疗保健决策权下放到西班牙各地区。权力下放是在二十年的时间里逐步和非对称地实施的（1981-2002 年）。各地区权力下放的顺序是由政治因素驱动的，因此可以认为与健康结果无关。此外，我们还利用卫生服务权力下放的动态效应，并允许通过在各地区实施的两种主要权力下放类型来实现异质效应：完全下放（政治和财政权力）与仅政治下放。我们基于 1980 年至 2010 年期间西班牙 50 个省份的面板数据集的差异中的差异结果表明，只有那些享有几乎完全财政和政治权力且属于最富裕地区的地区才能获得权力下放的持久收益。
