Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
Instituto de Salud Publica Andres Bello, Universidad Andres Bello, Santiago, Chile.
Health Syst Reform. 2022 Jan 1;8(1):e2064793. doi: 10.1080/23288604.2022.2064793.
A major theoretical issue about health system reform involving decentralization has been whether it promotes equity of health system funding. An article by the principal author and others in 2003 showed that, under certain conditions and policies, decentralization improved the equity of allocation of financial resources to different income levels of municipalities in Colombia and Chile. Another recurring issue has been whether reforms can be sustained over time. In a follow-up study in 2015, we found that the equity of national allocations was sustained even though the allocation rules for intergovernmental transfers and insurance funding sources had changed, as long as allocation rules were retained. Nevertheless, the wealthier municipalities in Chile were able to increase their own source funding contributing to a larger gap between wealthy and poor municipalities, suggesting that in order to assure continued equity some compensation for these funds be included in intergovernmental transfer rules or that local source funding be restricted by national policy. These reforms may be more likely to be sustained if they become embedded in existing financial systems and if they receive support of status quo constituencies.
关于分权的医疗体制改革的一个主要理论问题是，它是否能促进医疗体制筹资公平。主要作者等人在 2003 年发表的一篇文章表明，在某些条件和政策下，分权提高了哥伦比亚和智利不同收入水平的城市财政资源分配的公平性。另一个反复出现的问题是改革是否能够持续。在 2015 年的后续研究中，我们发现，即使政府间转移支付和保险资金来源的分配规则发生了变化，只要保留分配规则，国家拨款的公平性就得以维持。然而，智利较富裕的城市能够增加自己的资金来源，导致贫富城市之间的差距进一步扩大，这表明为了确保持续的公平性，应该在政府间转移支付规则中包括对这些资金的补偿，或者通过国家政策限制地方资金来源。如果这些改革能够融入现有的金融体系，并得到既得利益群体的支持，那么它们就更有可能持续下去。
