School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
Int J Health Policy Manag. 2023;12:7449. doi: 10.34172/ijhpm.2022.7449. Epub 2023 Jan 1.
The article by Rotulo and colleagues suggests that health sector fiscal decentralisation has been bad for Italy. But given the complexity of fiscal decentralisation, this interpretation is not necessarily so. Their analysis was based on assumptions about causality that are better suited for simple interventions. Assumptions of simplicity show up as misleading artefacts in the conclusion of evaluations of complex interventions. Complex interventions work by triggering mechanisms - eg, reasoning and learning processes - that manifest differently across the units of a decentralised system, contingent on context, evolving over time. Evaluation findings can only be partial and provisional; neither summarily good nor bad. The goal of evaluating a complex intervention - such as decentralised governance - should be to understand how, under what circumstances and for whom they are good or bad - at a point in time.
罗图洛等人的文章认为，卫生部门财政分权对意大利不利。但鉴于财政分权的复杂性，这种解释不一定正确。他们的分析基于对因果关系的假设，这些假设更适合简单的干预措施。简单性假设在对复杂干预措施的评估的结论中表现为误导性的人为产物。复杂干预措施通过触发机制（例如推理和学习过程）发挥作用，这些机制在分权系统的各个单位中表现不同，取决于具体情况，并随时间演变。评估结果只能是局部和暂时的；既不是简单的好或坏。评估一项复杂干预措施（如分散治理）的目的应该是了解在特定时间点，它们在何种情况下、对谁有利或不利，以及如何有利或不利。
