Rotulo A, Epstein M, Kondilis E
Laboratory of Primary Health Care, General Medicine and Health Services Research, School of Medicine, Aristotle University of Thessaloniki, Greece.
Institute of Population Health Science, School of Medicine and Dentistry, Queen Mary University of London, United Kingdom.
Hippokratia. 2020 Jul-Sep;24(3):107-113.
Fiscal federalism and fiscal decentralization are distinct policy options in public services in general and healthcare in particular, with possibly opposed effects on equity, effectiveness, and efficiency. However, the pertinent discourse often reflects confusion between the concepts or conflation thereof.
This paper performs a narrative review of theoretical literature on decentralization. The study offers clear definitions of the concepts of fiscal federalism and fiscal decentralization and provides an overview of the potential implications of each policy for healthcare systems.
The interpretation of the literature identified three different dimensions of decentralization: political, administrative, economic. Economic decentralization can be further implemented through two different policy options: fiscal federalism and fiscal decentralization. Fiscal federalism is the transfer of spending authority of a centrally pooled public health budget to local governments or authorities. Countries like the UK, Cuba, Denmark, and Brazil mostly rely on fiscal federalism mechanisms for healthcare financing. Fiscal decentralization consists of transferring both pooling and spending responsibilities from the central government to local authorities. Contrarily to fiscal federalism, the implementation of fiscal decentralization requires as a precondition the fragmentation of the national pool into many local pools. The restructuring of the pooling system may limit the cross-subsidization effect between high- and low-income groups and areas that a central pool guarantees; thus, severely affecting local equality and equity. With the limited availability of local public resources in poorer regions, the quality of services drops, increasing the disparity gap between areas. Evidence from Italy, Spain, China, and Ivory Coast -countries with a strong fiscal decentralization element in their healthcare services- suggests that fiscal decentralization has positive effects on the infant mortality rate. However, it decreases healthcare resources as well as access to services, fostering spatial inequities.
If public resources are and remain adequate, allocation follows equitable criteria, and local communities are involved in the decision-making debate, fiscal federalism -rather than fiscal decentralization- appear to be an adequate policy option to improve the healthcare services and population's health nationwide and achieve health sector economic decentralization. HIPPOKRATIA 2020, 24(3): 107-113.
财政联邦制和财政分权是公共服务领域，尤其是医疗保健领域不同的政策选择，可能对公平性、有效性和效率产生相反的影响。然而，相关论述往往反映出概念之间的混淆或合并。
本文对关于分权的理论文献进行了叙述性综述。该研究明确了财政联邦制和财政分权概念的定义，并概述了每项政策对医疗保健系统的潜在影响。
对文献的解读确定了分权的三个不同维度：政治、行政、经济。经济分权可以通过两种不同的政策选择进一步实施：财政联邦制和财政分权。财政联邦制是将集中统筹的公共卫生预算的支出权转移给地方政府或当局。英国、古巴、丹麦和巴西等国家在医疗保健融资方面大多依赖财政联邦制机制。财政分权包括将统筹和支出责任从中央政府转移到地方当局。与财政联邦制相反，财政分权的实施需要以将国家统筹资金分散为多个地方统筹资金为前提条件。统筹系统的重组可能会限制中央统筹资金所保障的高收入和低收入群体及地区之间的交叉补贴效应；从而严重影响地方的平等和公平。由于贫困地区地方公共资源有限，服务质量下降，地区间差距加大。来自意大利、西班牙、中国和科特迪瓦（这些国家的医疗服务中财政分权因素较强）的证据表明，财政分权对婴儿死亡率有积极影响。然而，它也减少了医疗资源以及服务可及性，加剧了空间不平等。
如果公共资源充足且持续充足，分配遵循公平标准，并且地方社区参与决策辩论，那么财政联邦制——而非财政分权——似乎是改善全国医疗服务和民众健康状况、实现卫生部门经济分权的适当政策选择。《希波克拉底》2020年，第24卷第3期：107 - 113页 。
